Regent Student/Faculty Spouse Registration Form

An asterisk (*) indicates a required field.

Name of Registering Spouse
(Last, First and Middle Initial):*
Name of Student/Faculty Member
(Last, First and Middle Initial):*
Local Street Address:*
City:*
State:*
Zip Code:*
Home/Cell Phone:*
Work Telephone:
Email Address:*
Patron Type: Regent Student Spouse
Regent Faculty Spouse