Personal Information > Background Evaluation 2 > Medical Information > Online Payment
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Personal Information: Please provide the information requested below. This form is due by May 1, 2024.
First Name
Middle

Preferred Name
 Please enter your preferred name here if it is different from your legal/given first name. 

Last


Student emails are created with a combination of letters and numbers but names are displayed in the directory. Please indicate below how you would like your full name to appear (i.e. first and last name or preferred name and last name).
HUC Student Email Preference
(100 characters max.)

characters left

Date of Birth
  (mm/dd/yyyy)

SSN/Government Id
 US DOE requires reporting on all students who have received FED aid during their academic tenure. This reporting is made via the NSLDS, which requires SSN in order to identify students. This will never be shared outside of this federally-mandated reporting 

Country of Current Address
 The page will refresh when the current country is changed. 

Current Address
Apt./Unit

Current City
State/Province
Postal Code

Email Address

Day Phone Country
 Enter Phone Country 

Area Code
  
Phone


    required and     optional