Student Information - Redeemer Forms

Student Name*

First Last

RUC Student Id number

Student Email address*

EMERGENCY CONTACT INFORMATION*

Do you consent for Redeemer to contact your emergency contact in case of a serious incident?

Full Name of Contact*

First Last

Relationship to student*

Primary number*

Work/other phone number

Email address*

Additional emergency contact information

Click here to add the name of an additional emergency contact (optional)

Full name of seconday contact

First Last

Relationship to student*

Primary number*

Work/other phone number

Email address*

MEDICAL INFORMATION*

Name of family doctor

Doctor's phone number*

Health Coverage*

All students are required to have medical coverage and are encouraged to visit a physician annually. * Canadian students are typically fully covered by provincial insurance plans, like the Ontario Health Insurance Plan (OHIP), and do not require any further coverage. * Students from outside of Canada will automatically be enroled in the international health insurance program. Additional fees will apply. Please contact the Student Life Department at stlife@redeemer.ca for more details. Do you have Canadian provincial health coverage?

Health Card number

Issuing Province

Health Conditions*

Please list any health related conditions that you want to disclose to Redeemer University College. Please check all that apply:

Allergies
Corrective lenses (during physical activities)
Medical conditions
Mediciations
Sustained injuries

Please specify:

Do you want to share any other important medical information?

Authorized release*

I authorize release of this information to the necessary personal at Redeemer University College.

CHURCH INFORMATION

Name of Church

Church Demonination

Province/State

PARENT/GUARDIAN AND SPOUSE INFORMATION*

Would your parent(s) or guardian(s) like to be contacted with occasional updates regarding school information and events?

Yes
No

Name

First Last

Relationship to student

Phone

Email address

This parent/guardian is an alumni of Redeemer.

Yes
No

Is this parent/guardian's address DIFFERENT than your permanent address?

Yes
No

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Would you like to add the name of another parent or guardian?

Yes
No

Name

First Last

Relationship to student

Phone

Email address

This parent/guardian is an alumni of Redeemer.

Yes
No

Is this parent/guardian's address DIFFERENT than your permanent address?

Yes
No

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Would you like to add the name of your spouse (if applicable)?

Yes
No

Spousal Name

First Last

Previous/Maiden Name (if applicable)

Phone

Email address