Student Family Profile

Student Information

First Name*

Middle Name

Last Name*

Nickname

Loyola ID Number

Parent or Guardian 1 Information

Parent or Guardian

Father

Mother

Stepfather

Stepmother

Other

If other, please specify

Is Parent or Guardian living or deceased?

Living

Deceased

Prefix

First Name

Last Name

Suffix

Nickname

Date of Birth

Current Marital Status

Married

Divorced

Separated

Remarried

Widowed

Single

If Remarried, Spouse/Stepparent's First Name

If Remarried, Spouse/Stepparent's Middle Name

If Remarried, Spouse/Stepparent's Last Name

Home Street Address

City

State

Zip Code

Country (if outside U.S.):

International postal code (if applicable):

Home Phone Number:

Cell Phone Number:

Preferred Email Address:

Confirm Email Address:

Employer

Employer's Address

Type of Business

Position or Title

Business Phone

Business Email

In an effort to assist our students with both career exploration and career connections, would you be willing to have our career center contact you to discuss mentoring and internship/job opportunities within your organization?

Yes

No

List the Colleges/Universities Attended and the Type of Degree

List all Civic, Fraternal, Religious, Political, Volunteer Memberships

Parent or Guardian 2 Information

Parent or Guardian

Father

Mother

Stepfather

Stepmother

Other

If other, please specify

Is Parent or Guardian living or deceased?

Living

Deceased

Prefix

First Name

Last Name

Suffix

Nickname

Date of Birth

Current Marital Status

Married

Divorced

Separated

Remarried

Widowed

Single

If Remarried, Spouse/Stepparent's First Name

If Remarried, Spouse/Stepparent's Middle Name

If Remarried, Spouse/Stepparent's Last Name

Home Street Address

City

State

Zip Code

Country (if outside U.S.)

International postal code (if applicable)

Home Phone Number

Cell Phone Number

Preferred Email Address

Confirm Email Address

Employer

Employer's Address

Type of Business

Position or Title

Business Phone

Business Email

In an effort to assist our students with both career exploration and career connections, would you be willing to have our career center contact you to discuss mentoring and internship/job opportunities within your organization?

Yes

No

List the Colleges/Universities Attended and the Type of Degree

List all Civic, Fraternal, Religious, Political, Volunteer Memberships

Legacy Information

Is any family member a current student, alumnus, or alumna of Loyola College/University or Mount Saint Agnes College? If yes, please list the name(s), class year(s) and relationship to student.

Relative 1 Name (Last, First, M.I.)

Relative 1 Relationship to Student

Relative 1 Degree Earned

Relative 1 Year

Relative 1 School

Loyola College or University

Mount Saint Agnes College

Relative 2 Name (Last, First, M.I.)

Relative 2 Relationship to Student

Relative 2 Degree Earned

Relative 2 Year

Relative 2 School

Loyola College or University

Mount Saint Agnes College

Relative 3 Name (Last, First, M.I.)

Relative 3 Relationship to Student

Relative 3 Degree Earned

Relative 3 Year

Relative 3 School

Loyola College or University

Mount Saint Agnes College

Relative 4 Name (Last, First, M.I.)

Relative 4 Relationship to Student

Relative 4 Degree Earned

Relative 4 Year

Relative 4 School

Loyola College or University

Mount Saint Agnes College