10/10/14 8:25 AM
Admissions & Records
Student Change of Information
This form must be submitted with valid photo ID. If you are providing or correcting your social security number you
must provide your social security card. Before submitting this form to Admissions & Records district employees must
contact the Human Resources Office and student employees must contact the Student Employment Office. Please use
BLACK OR BLUE INK ONLY.
Name on File: ____________________________________________________________________________
Last Name First Name Middle Initial
Student ID or SSN: _______________________________ Date of Birth: __________ __________ __________
Month Day Year
Name Change:
You must attach a copy of a legal document reflecting your new name. Your original WebAdvisor User ID,
RCCD student email address, and Blackboard login will not change.
New Name:
______________________________________________________________________________
Last Name First Name Middle Initial
Address Change:
Permanent Address (required):
______________________________________ ______________________________ _____ ____________
Number and Street Apt# City State Zip
Mailing Address (if different from Permanent Address):
______________________________________ ______________________________ _____ ____________
Number and Street Apt# City State Zip
Phone Number: ___________________________________ Release Directory Information:
Yes No
Admit Status Change:
First-Time College Student Transfer Student Returning Student
Concurrent High School Student (enrolled in high school and college at the same time)
High School Information Change:
I received a high school diploma from _______________________________ located in _____________________.
Name of School City, State OR Foreign Country
I started attending this high school in ___________ and graduated in ___________.
Month/Year Month/Year
I received my G.E.D. from _______________________________, located in _____________________, in ___________.
Name of School City, State OR Foreign Country Month/Year
I passed the California High School Proficiency Exam at _______________________________ in ___________.
Name of School Month/Year
Other Changes: ___________________________________________________________________________
Student Signature: _________________________________ Date: _____________
It is strongly recommended that you talk to a counselor before making the following changes:
Academic Program Change: ______________________ Educational Goal Change: _______________
___________________
click to sign
signature
click to edit
![]()
