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Change of Personal Data Request Form

Change of Personal Data Request Form (24.7KB file)

• Social Security number or student ID number.
• Program and year of graduation (if applicable).
• Current address and daytime telephone number.
• Date of request.
• Request must have the student's signature. Requests made by others on behalf of the student will not be accepted.
• Request may be mailed or faxed. Visit our Contact page for forwarding address and contact numbers.

Change of Name

• Former name (last, first and middle name or initial).
• New name (last, first and middle name or initial).
• A copy of the legal documentation that supports the name change must accompany request. Legal documentation can include the following: naturalization certificate, marriage license, divorce decree, driver's license, social security card etc.

Change of Address

• The date the change should be effective.
• The mailing address/telephone type that is being changed (mailing, permanent or emergency contact).
• The new complete address (street address, city, state and zip).
• The new telephone number (including area code).
• If the change is for emergency contact, list the contact name and the relationship to student (mother, spouse etc.).
• If student is an international student, please indicate on request.

Additional Information

• All University departments will have access to the updated information through the Banner SCT Student Database System.
• The Family Educational Rights and Privacy Act of 1974 (FERPA) allows Western University of Health Sciences to release certain directory information about students without written consent. This information includes, in part, name and address/telephone information. To view more information about FERPA, please visit our Student Privacy Rights page.