Updated January 2021 SSC
Change of Student Information Form
Information must be printed or typed in black or blue ink. (Penciled forms will not be accepted.)
Student name and ID (Required)
Student ID number: ____________________________________________________________
(If Student ID is unknown, provide last 4 digits of SSN and Full DOB)
Legal Name: _____________________________________________________________
Last First Middle
Preferred Name: ______________________________________________________________
Last First Middle
Change of Address (please see Residency Change Form regarding Residency Policy)
New Address: ________________________________________________________________
Street Address City State Zip
Public School District for New Address: □Crawford County R-1 (Bourbon) □New Haven □St. Clair R-
13 □Sullivan C-2 □Union R-11 □Washington □Franklin Co. R-2 □Lonedell R-14 □Spring Bluff R-15
□Strain-Japan R-16 □Other (specify district & city) _________________________________________
New Phone Number: (_____) ___________________________________________________
New Cell Number: (_____) ____________________________________________________
New E-mail: __________________________________________________________________
Legal Name Change Request (Must provide proof of legal name change)
New Legal Name: ___________________________________________________________
Last First Middle
Former Legal Name: ___________________________________________________________
Last First Middle
Preferred Name Change Request
New Preferred Name: _________________________________________________________
Last First Middle
Former Preferred Name: _______________________________________________________
Last First Middle
Change email address & eCentral/Moodle UserID to reflect new preferred name? □ Yes □ No
(This may affect access to emails under previous email address.)
Student Signature (Required): _________________________________ Date: ___________
