New Student Registration Survey

Student Information

Legal First Name

Middle Name

Last Name

Preferred Name

My gender identity

Male

Female

Non-Binary

The biological sex I was assigned at birth

Male

Female

Email Address

Cell Phone

Date of Birth

Home Address

Country

Street

City

Region

Postal Code

Is your billing address the same as your home address?

Yes

No

Billing Address

Country

Street

City

Region

Postal Code

Are you Hispanic or Latino?

Yes

No

Please select one or more of the following to indicate race.

What is the highest level of school your first parent or guardian has obtained?

What is the highest level of school your second parent or guardian has obtained?

Student Contact(s) Information

In this section, please provide your contact information - parent(s) and/or other (guardian, spouse, etc.)

I live with

Both Parents

Father

Mother

Someone other than parent (guardian, grandparent, sibling, spouse, etc.)

Father's Name

Father's Address

Country

Street

City

Region

Postal Code

Father's Email

Father's Cell Phone

Mother's Name

Mother's Address

Country

Street

City

Region

Postal Code

Mother's Email

Mother's Cell Phone

Emergency Contact Information

Each student, faculty, and staff member must provide an emergency contact. The information you provide is kept on file in the event of an emergency. Please provide phone numbers for all your emergency contacts.

My Emergency Contact is listed above.

Yes

No

Emergency Contact 1 Name

Emergency Contact 1 relationship to me

Emergency Contact 1 Phone

Emergency Contact 1 Email

I would like to list an additional emergency contact.

Yes

No

Emergency Contact 2 Name

Emergency Contact 2 relationship to me

Emergency Contact 2 Phone

Emergency Contact 2 Email

Emergency Contact 3 Name

Emergency Contact 3 relationship to me

Emergency Contact 3 Phone

Emergency Contact 3 Email

Family Education Right to Privacy Act (F.E.R.P.A.)

The F.E.R.P.A. guidelines are listed here.

I have read the F.E.R.P.A. statement and understand each of the following items described.

Yes

Directory Information

Yes

No

Who may access? Provide name(s), Relationship(s), and Phone Number(s).

Name(s) for Directory Information

Relationship to you for Directory Information

Phone Number for Directory Information

Public Relations

Yes

No

Please provide information if you would like your parents/gaurdians identified in any news releases (son or daughter of). Provide name(s), city, state, and relationship to you.

Name(s) for Public Relations

Relationship to you for Public Relations

City for Public Relations

State for Public Relations

Student Record Access

Yes

No

Who may have access? Provide name(s), relationship(s), and phone number(s)

Name(s) for Student Records

Relationship(s) to you for Student Records

Phone Number(s) for Student Records

Student Account Information Access

Yes

No

Who may have access? Provide name(s), relationship(s), and phone number(s)

Name(s) for Student Account Information

Relationship to you for Student Account Information

Phone Number for Student Account Information

Work Program

In order to receive the Blackburn Work Grant, you must be a full-time student to participate in the Work Program. All resident students, living in campus housing, must participate in the Work Program.

I will participate in the Work Program

Yes

No

Based upon the current residency policy of Blackburn College, I will be a

Resident student living in campus housing

Commuting student living off campus

Academic Survey

I intend to earn a degree from Blackburn

Yes

No

I will be entering Blackburn as a

New College Freshman

Transfer Student, previously enrolled in another university

Other

Please identify the program you will be entering

I will be registering as a

Full-Time Student , taking 12 or more credit hours

Part-Time Student, taking less than 12 credit hours

What major(s) do you plan to pursue?
Click here to see a list of all of the majors and minors we offer!

What are your career goals?

Are you interested in becoming a teacher?

Yes

No

What subject or grade levels are you interested in?

Are you interested in joining choir? You don’t need to be a music major to participate.

Yes

No

Are you interested in participating in theater? You don’t need to be a theater major to participate.

Yes

No

Did you take Spanish in high school?

Yes

No

How many years of high school Spanish?

What was the highest level math class you took in high school?

Did you take any dual enrollment, or dual credit, courses in high school?

Yes

No

Please list the institution and the courses completed.

Did you take any AP exams? (Official Score Reports must be submitted from College Board.)

Yes

No

Please list those exams with scores if known.

Is there anything else you want the advisor who will meet with you to know?

Submission Authorization

Be sure to have official copies of your final high school transcript sent to our Admissions Office. If you have AP credits, or have attended any college or university, official transcripts must be submitted to be evaluated. Our Records Office will evaluate your college credits for transfer.

I understand that by typing my name below, I certify that the information provided on this registration form is true and accurate. I authorize Blackburn College to enter into my student record the information I have provided on this form.

I have read and understand the Submission Authorization statement above.

Yes

Type your full legal name here.