Student’s Name: ID#:
Street or Box # City State Zip
New Address: ☐ Legal Home/Permanent ☐ Current/Temporarily Living
☐Home ☐ Cell
New Phone Number:New Email: __ __________________________________ __________________
Current Marital Status: ☐ Married ☐ Single Name changed to*: ____________________________________
Student email addresses will be updated to the new firstname.lastname@example.org by the IT Department within 48 hours.
Emergency Contact Change: ☐Yes ☐ No Emergency Contact: __________________________________
☐Home ☐ Cell ☐ Work Emergency Contact Phone Number: __________________
Date: __Student’s Signature: _______________________________________________ ______________________
*Must present documentation of the name change. Documents accepted include Marriage Certificate, Certified Record of Divorce, Certified Court
Order, valid unexpired U.S. Passport issued in your current name, or Social Security Card issued in your current name.
Office Use Only Entered by: ____________
☐Records Management Group Notified ☐ IT Services Notified ☐Current Instructors Notified 07/2019
Western Dakota Tech
800 Mickelson Dr.
Rapid City, SD 57703