Student’s Name: ID#:
New Address:
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 first.last@stu.wdt.edu 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.
Initials Date
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
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