Student Contact Information Form

The Department of Education and School Psychology (DESP) needs YOUR help to ensure we have the most up-to-date student records. Unfortunately, if you update your records with the registrar we do not receive the update automatically. Therefore, we ask that you please complete the below form and submit by September 30th. Should you have any further updates or changes to your record, please contact Deb Petraska (DESP Licensure) at education@jcu.edu or 216-397-4389.

DESP Student Contact Information Form

Today's Date (MM/DD/YY):

Program(s) and/or Licensure Area:

Course:

Please select the course from the drop down box above.

Professor:

First Name:

Middle Initial:

Last Name:

Banner ID:

Preferred Email (JCU or Personal):

Local Street Address:

*this is the address you use during the school year.

Local City:

*this is the city you use during the school year.

Local State:

*this is the state you use during the school year.

Local Zip Code:

*this is the zip code you use during the school year.

Permanent Street Address:

*this is the address you use permanently (out of school).

Permanent City:

*this is the city you use permanently (out of school).

Permanent State:

*this is the state you use permanently (out of school).

Permanent Zip Code:

*this is the zip code you use permanently (out of school).

Cell Phone:

Please be sure to include area code.

Permanent Home Phone:

*this is the phone number used as a permanent home phone.

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