Student Staff Information Form

Last Name *

First Name *

Preferred first name

For name tags, door tags, etc.

Hometown (City, State or Country)

Position *

RA

CA

Placement *

Please include residence hall and room number

Columbia email address *

Alternate email address

Cell phone number *

School *

Columbia College

School of Engineering and Applied Science

Graduation Year *

2014

2015

2016

Other

Birthday *

Month, Day, Year ex.: 09/25/1990

T-shirt size (unisex) *

Dietary restrictions *

Please list any dietary needs or enter "none"

Major(s) *

Concentration(s)

Clubs/Organizations/Affiliations

Plans & Aspirations Post-Columbia

Passions & Personal Interests

Are you a student who transferred to Columbia? *

Yes

No

Are you an international student? *

Yes

No

Do you currently work for another university department? *

If yes, please include office/department name, supervisor name and contact information.

Anything else Residential Programs should know about you?

i.e., Do you keep Sabbath? Do you celebrate Ramadan? This will help us best support you.

Summer Mailing address *

Permanent Home Mailing Address *

If same as summer mailing address, list "Same"

Parent/Guardian Name (First and Last) *

Parent/Guardian email address

Rider Name(s), if applicable (First and last)

If you do not have a rider, please enter "none"

Rider(s) Columbia email address(es)

Rider(s) Cell phone number(s)

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Student Staff Information Form

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