MLS On-Campus Student Information Form

If you are an on-campus MLS student, please fill in the following information:

   The information we are requesting is very important to us. It will be stored in your student records file and in an electronic database in the MLS Department, in accordance with the WSU information security policy. Your information will be used only by the faculty and staff of the MLS Department.
 Make sure you have all the information you need for each question before you begin.
 You can use the TAB key to move from field to field.

Last Name: * First name: *

W ID number * (do not include the letter "W")

Date of birth (mm/dd/yr): *        Male/Female: *

US citizen:*    If not US citizen, enter country of citizenship: *

Ethnicity: *

Address: *

City:  * State:  * Zip: *

Wildcat email address (

Alternate email if you do not use often: *

Home phone (555-555-5555):  *  Cell phone: *

Can we contact you using a cell phone text?  (do not check if your answer is no)

Which MLS program will you be in for this coming fall semester? (check only one box):*

       MLT (2 year A.A.S. program)      MLS (4 year B.S. program)  
Are you Pre-professional (i.e. medical, dental, veterinary, or physician assistant)?:

     Person to notify in case of emergency:

Person's name: *

Relation to you: *

Address (include at least city and state): *

Phone number (include area code): *

2nd phone number: *

      Employer information:

Are you employed by IHC? *  By ARUP? *

If not, employer's name: *

Address (include at least city and state): *

Department that you work in: *

Your title at work: *

Work phone (include area code): *

Briefly explain how you heard about the MLS program (please limit your answer to two or three sentences):

Today's date (mm/dd/yr): *

NOTE:  After you hit the Submit button, you cannot come back to this form and change any data, so make sure what you have is correct before continuing.  You will be graded on your responses (just kidding!)
Thanks for your time.  MLS Department