Demographic Form 22-23

McPherson College

Demographic Form

McPherson College asks that each student complete this demographic form once a year.

You will need your McPherson College Student ID # to complete this form.
Email admiss@mcpherson.edu if you need assistance finding your ID#.

Please note: McPherson College requires that the student complete this documentation. We believe that it is important for the student to take this responsibility. If problems are encountered, please ensure it is the student who contacts McPherson College.

Questions? Email housing@mcpherson.edu or call 620-242-0500

Student Information

Student ID # (last six digits)

First Name

Last Name

Do you have another name you'd rather be called?

Yes

Preferred Name

Student Birthdate

Student Cell Phone Number

Student's Personal Email (do not use a school address)

Emergency Contacts

Emergency Contact #1

Contact #1 First Name

Contact #1 Last Name

Relationship to you:

Contact #1 Email

Contact #1 Phone Number

Contact #1 Street Address

Contact #1 City

Contact #1 State

Contact #1 Zip

Emergency Contact #2

Contact #2 First Name

Contact #2 Last Name

Relationship to you:

Contact #2 Email

Contact #2 Phone Number

Contact #2 Street Address

Contact #2 City

Contact #2 State

Contact #2 Zip

Mental Health

Have you ever been diagnosed with any mental illnesses?

Yes

Please list all mental illnesses

Have you ever been hospitalized as a result of mental illnesses?

Yes

Reason for hospitalization and duration of stay

Please list any prescription medications you take as a result of mental illness

Have you ever attempted suicide?

Yes

Physical Health

Do you have health insurance?

Yes

Please upload a picture of your current Insurance Card

Please upload a picture of your current Immunization Record

Please select each of the following physical health problems that you have experienced within the last 3 years

Please specify

Have you had any of these medical problems?

Please specify

Please list any medications you take that were not listed previously on this form

Please list any allergies that you have

How Can We Help?

If we can help by providing more information to make your Bulldog experience even better, please be sure to select that you'd like more information about these specific topics.

Please check all items that you would like more information about

Mental health services/counseling

Our on-site health clinic

Other