Information Needed from Student to Establish web4parent Access

Please print this form, complete, and submit it to the Office of Registration and Records for processing.  All information requested must be completed before access can be granted.  The completed form must arrive in our office by one of the following methods:  By regular mail (Office of Registration and Records, Parsons Hall room 009, Indiana State University, Terre Haute, IN, 47809; by fax (812-237-8039), or by delivering it to our office in person. The FAQ's may be viewed at   http://www1.indstate.edu/registrar/web4parent_student_faq.html

Student’s Last Name: ______________________________________________________ 

Student’s First Name: ____________________ Middle Name: ____________________

Student's Identification Number:  __ __ __-__ __ __ -__ __ __

Student's ISU e-mail address:  _____________________________

Parent’s Last Name: ______________________________________________________ 

                                   (any previous last names and/or maiden name)

 Parent’s First Name: ____________________ Middle Name: ____________________

Parent’s Social Security Number:  __ __ __-__ __ -__ __ __ __

Parent’s Date of Birth:  __ __/__ __/ __ __ __ __ 

                                          (MM/DD/YYYY)

 Relationship to Student:            

• Parent
• Legal Guardian
• Other:  ___________________________________________________________

                         (Explanation)

Parent’s email address:  ___________________________________________________

Parent’s current mailing address:

Street:  ________________________________________________________________   

City:   _________________________________________________________________

State:  ___________________    Zip:  ______________

Daytime phone number: (__ __ __)-__ __ __ -__ __ __ __

Have you ever been affiliated with ISU? 

• Student  (insert ISU identification number field if selected)      __ __ __-__ __ __ -__ __ __
• Alumni   (insert ISU identification number field if selected)      __ __ __-__ __ __ -__ __ __
• Employee  (insert ISU identification number field if selected)  __ __ __-__ __ __ -__ __ __
• Donor
• None
• Other:  ____________________________

I certify that the information I have provided on this form is true and accurate.

Student's signature ____________________________                         Date ________________

Parent's signature _____________________________                         Date ________________