Name: 
Current Address: 
City:     State:     Zip: 
Telephone:      E-mail: 
Cell Phone: 

If you plan to move to Fort Wayne and will be changing your current address listed above, when do you plan to relocate?

Academic year: 2007-08 2008-09

Program of Study: 
     M.Div. - I   II   III   IV  
     M.Div. - ALTS student
     Alternate Route - Level 1   Level 2  
     Deaconess M.A. - Level 1   Level 2
     M.A. - degree only
     STM
     D.Min.
     Ph.D.

Anticipated enrollment level for each term:

Anticipated date for completion of your program: 

Those enrolled in programs leading to LCMS church work vocations (Pastor or Deaconess) please complete the following information.

Home congregation name:

Home congregation address:

City: State: Zip:
Pastor: 
LCMS District:    

Marital status:  Single    Married    Engaged
If engaged, anticipated wedding date: 
Name of spouse/fiancee: 

Names of dependent children and their dates of birth:
1.
2.
3.
4.
5.
6.