Oregon State University
Please enter your student information below.
First Name:
*
Last Name:
*
Only if different than name above:
Pronouns in use:
Date of birth:
*
Student ID (no dashes or spaces):
*
Required Contact Phone Number (Cell Required):
*
Text messaging:
*
Use Required Contact Phone Number (Cell Required)
Do not send text messages
Email:
*
I understand this is a required field for a counselor to contact me. If I have concerns I will contact CAPS to make other arrangements.
*
Yes
No
Local Address *include city, state, zip*:
*
OK to contact at Address1?
Yes
No
2nd Address (if applicable):
OK to contact at Address2?
Yes
No
Current Physical Location: City & State
*
EMERGENCY CONTACT: Name, Phone Number, Relationship to you.
*
Nearest Hospital and Phone Number (If in Corvallis: Samaritan Health Services 541-768-5021):
*
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for,
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