STUDENT INFORMATIONCurrent Semester*Last Name*First Name:*Current Address:* Permanent Address:* Home:* Health Coverage:*YesNoDo you intend to drive on the Island?*YesNoPASSPORT / DRIVER’S LICENSE / HEALTH INSURANCEStudent Passport No.** USA/Canada Other Date of Issue*Expiration Date*Passport Issued out of*(name city & State and/or country)Health Insurance CarrierPolicy No.Policy Period From: Policy Period To: Local Driver’s License No.Date of Issue Expiration Date IAU Email* Alternate Email:* Permanent Phone*Local Phone*Landlord Name:*Landlord Phone #:*On-Island Emergency Contact:*Phone #:*Off-Island Emergency Contact:*Phone #:*ACADEMIC INFORMATIONSemester/Term Last Attended:*PM1PM2PM3PM4MD1MD2MD3MD4i.Subjects/Courses Taken:*Passing Grade*ii.Subjects/Courses Taken:*Passing Grade*iii.Subjects/Courses Taken:*Passing Grade*iv.Subjects/Courses Taken:*Passing Grade*v.Subjects/Courses Taken:*Passing Grade*PROGRAM*SEMESTER*i. SUBJECTS TO BE TAKEN*ii. SUBJECTS TO BE TAKEN*iii. SUBJECTS TO BE TAKEN*iv. SUBJECTS TO BE TAKEN*v. SUBJECTS TO BE TAKEN*PAYMENT INFORMATIONSeat deposit:Amount:*Paid*YesNoTuition & Fees:Amount:*Paid*YesNoType of Payment:* MED LOANS CHECK (Payable to IAU) CASH Credit Card (Attach Credit Card Authorization Form) Amount:*Check #*Amount:*Amount:*Student Name*Date* CommentsThis field is for validation purposes and should be left unchanged.
