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PROSPECTIVE STUDENTS STUDENTS ALUMNI/AE LIBRARY FACULTY ACADEMICS

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Biographic/Demographic Survey

This form is required of all students prior to starting coursework at the University of Connecticut School of Law. The information gathered is used to update a student’s profile in the student administration system database and for statistical purposes. Please note student directory information, including some of the data requested on this form (Name, Address, Telephone Number, and Program of Study) may be provided upon request to members outside of the community of the School of Law as permitted under the Family Educational Rights and Privacy (or FERPA) of 1974. Students wishing to limit the disclosure of this information must file a written request with the Office of the Registrar on an annual basis.

Biographical/Demographic Information

First name (required)
Middle name
Last name (required)
Date of Birth (MM-DD-YYYY ) (required) Month: Day: Year:
Gender (required) Male
Female
Transgender
Citizenship Permanent Alien
Temporary Alien (Please complete the INS Biographic form)
Native U.S. Citizen
Naturalized
Marital Status
Single
Separated
Common Law
Divorced
Widowed		 Head of Household
Married
Domestic Partnership
Other
Ethnicity
Alaskan/American Native
Asian
Black/African American
Canadian Aboriginal
Caucasian/White 		Hispanic
Mexican American/Chicano
Other
Pacific Islander
Puerto Rican
Veteran's BenefitsI am eligible for Veteran's benefits
Military Status Active/Reserve
Inactive Reserve
No Military Service
Retired
Program of Study (required) Juris Doctor (J.D.)
3-Year Day Division
4-Year Day Division
4-Year Evening Division

Master of Legal Letters (LL.M.)
US Legal Studies
Insurance Law

Non-matriculating
Visiting Student
Exchange Student
Auditing Student

Mailing/Billing address and Telephone

Address1 (required)
Address2
City (required)
State (required)
ZIP (required)
Phone (required)
Cellphone
E-mail (required)

Home/Permanent Address and Telephone

Address1
Address2
City
State
ZIP
Phone
Cellphone
E-mail

Business Address and Telephone

Address1
Address2
City
State
ZIP
Phone
Cellphone
E-mail

Health Information/Immunization

Connecticut state law requires that all matriculating students at post-secondary schools in the state provide proof that he/she meets the criteria of adequate immunization. This form is required of all students prior to starting coursework at the University of Connecticut School of Law. The information gathered is used for statistical purposes. Personally identifiable information will be kept confidential unless in cases of serious health emergency or outbreak

State law defines adequate immunization as any of the following

  • An affidavit signed by a physician/nurse practitioner that indicates that a blood test shows measles and rubella immunity.
  • Verifiable proof that a student has had two doses of measles vaccine at least one month apart (the first does must have been received after 1968, the second dose must have been received on/after January 1, 1980), and one does of rubella vaccine.
  • Graduation from a public or non-public high school in the state of Connecticut in 1999 or later.
  • An affidavit signed by the student that indicates that he/she will not receive vaccines on religious grounds.
  • An affidavit signed by a physician/nurse practitioner that indicates that vaccination is medically inadvisable and the reasons for the same.

Persons born before January 1, 1957 are exempt from this requirement as they are presumed to be naturally immune.

Please check one of the following (required):

I have graduated from a public or non-public high school in the state of Connecticut in 1999 or later.
I was born before January 1, 1957
The above do not apply, I will complete/submit the Immunization Form

      
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