PARENTS: Thank you for taking the time to complete this secure information form so that we can provide you with timely information that pertains to your student. This information is used only by university officials.

An asterisk (*) indicates a required field.
Note: Please allow 72 hours for this action item to be checked off on your student's checklist.
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Student Contact Information

Student ID#: *ex: 09944123

Student First Name:*

Student Middle Initial:

Student Last Name:*

Student Nickname:

Student Date of Birth: * mm/dd/yyyy

Gender: *

Secondary School:

Home Mailing Address Line 1:*

Home Mailing Address Line 2:

City: *

State/Province/Region: *

Zip/Postal Code: *

Country: * Select "Other" if your country is not listed

Home Phone: * 123-123-1234
If the student does not have a home phone, please type in all 0's.
International student's type in all 0's and contact the Orientation Office

Student Cell Phone: * 123-123-1234
If the student does not have a cell phone, please type in all 0's.
International student's type in all 0's and contact the Orientation Office

Student E-mail Address:*

An asterisk (*) indicates a required field.

Parent/Guardian 1 Contact Information

Prefix: *

First Name:*

Middle Initial:

Last Name:*

Suffix:

Date of Birth: *mm/dd/yyyy

Relationship to Student: *

E-Mail Address:*

LinkedIn URL:

Home Mailing Address Line 1:*

Home Mailing Address Line 2:

City: *

State/Province/Region: *

Zip/Postal Code: *

Country: * Select "Other" if your country is not listed

Home Phone: * 123-123-1234
If the student does not have a home phone, please type in all 0's.
International student's type in all 0's and contact the Orientation Office

Cell Phone: * 123-123-1234
If the student does not have a cell phone, please type in all 0's.
International student's type in all 0's and contact the Orientation Office

Fairfield University can contact me on my cell phone by:

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An asterisk (*) indicates a required field.

Parent/Guardian 2 Contact Information

Prefix:

First Name:

Middle Initial:

Last Name:

Suffix:

Date of Birth: mm/dd/yyyy

Relationship to Student:

E-Mail Address:

LinkedIn URL:

Home Mailing Address Line 1:

Home Mailing Address Line 2:

City:

State/Province/Region:

Zip/Postal Code:

Country: Select "Other" if your country is not listed

Home Phone: 123-123-1234
If the student does not have a home phone, please type in all 0's.
International student's type in all 0's and contact the Orientation Office

Cell Phone: 123-123-1234
If the student does not have a cell phone, please type in all 0's.
International student's type in all 0's and contact the Orientation Office

Fairfield University can contact me on my cell phone by:

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Parent/Guardian 1 Business Information

Employer:

Title:

Occupation:

Retired?

Work Mailing Address Line 1:

Work Mailing Address Line 2:

City:

State/Province/Region:

Zip/Postal Code:

Country: Select "Other" if your country is not listed

Work Phone: 123-123-1234

Work E-Mail Address:

Parent/Guardian 2 Business Information

Employer:

Title:

Occupation:

Retired?

Work Mailing Address Line 1:

Work Mailing Address Line 2:

City:

State/Province/Region:

Zip/Postal Code:

Country: Select "Other" if your country is not listed

Work Phone: 123-123-1234

Work E-Mail Address:

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An asterisk (*) indicates a required field.

Other Information

Parent/Guardian 1

Parent/Guardian 2

Undergraduate School

Year

Undergraduate School

Year

Graduate School

Year

Graduate School

Year

Interests/Hobbies:
Hold the ctrl key down to select more than one interest

Parent's Marital Status *

With Whom Does the Student Reside?*

Mother's Maiden Name *

Parent1 Living*

Parent2 Living*

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Parent/Guardian 1 Family Seasonal Address (if any) - to be used for invitations for regional events

Seasonal Mailing Address Line 1:

Seasonal Mailing Address Line 2:

City:

State/Province/Region:

Zip/Postal Code:

Country: Select "Other" if your country is not listed

Phone:

Parent/Guardian 2 Family Seasonal Address (if any) - to be used for invitations for regional events

Seasonal Mailing Address Line 1:

Seasonal Mailing Address Line 2:

City:

State/Province/Region:

Zip/Postal Code:

Country: Select "Other" if your country is not listed

Phone:

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Other Children

Child 1

First Name:

Last Name:

Gender:

Date of Birth: mm/dd/yyyy

Name of School:

Year in School:

Child 2

First Name:

Last Name:

Gender:

Date of Birth: mm/dd/yyyy

Name of School:

Year in School:

Child 3

First Name:

Last Name:

Gender:

Date of Birth: mm/dd/yyyy

Name of School:

Year in School:

Child 4

First Name:

Last Name:

Gender:

Date of Birth: mm/dd/yyyy

Name of School:

Year in School:

Child 5

First Name:

Last Name:

Gender:

Date of Birth: mm/dd/yyyy

Name of School:

Year in School:

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Fairfield University

Parent/Guardian Information Form

Parent/Guardian Information Form

Parent/Guardian Information Form

Parent/Guardian Information Form

Parent/Guardian Information Form

Parent/Guardian Information Form

Parent/Guardian Information Form

Parent/Guardian Information Form

Parent/Guardian Information Form