Name of  college or university **

City and State where college or university is located

Name of the student **

Home street address of the student **

Apt. number if applicable

City**   State**   Zip

Home phone number including area code if known

Email address if known

The next 4 items are particularly important if the student is already on campus, but would probably not be known if they are not. Campus ministers on many colleges and universities do not have access to this information.

College or university living location of the student if known

Room or Apt. number if applicable

City   State   Zip

Student's college or university phone number including area code if known

Click whichnew studenttransfer student  graduate student

Name of person submitting information **

Email address of person submitting information **

Additional information you would like the campus minister to have:

email address of campus minister if you know it (that information is available for many campus ministers on the state pages accessible from the home page)