New Student Referral Form
Welcome! Please use this form to share new or current student information with Rose House LuMin- Lutheran Campus Ministry at Indiana University Bloomington. This information will be used to help our ministry reach out and attempt to connect with the students who were referred to let them know they are welcome at Rose House and what services we offer. Thank you for your help.
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Student's First Name *
Student's Last Name *
Student's Preferred Pronouns (if known)
*
Student's Anticipated Graduation Year (if known)
Student's Email Address
Student's Phone Number
Student's Local to IU Address (if known)
Student's Permanent Address (if known)
Name of Student's Home Congregation & Congregation City/State (if applicable)
Food Allergies/Dietary Preferences (if known)
Other Information You Wish to Share About Student
Name of Person Referring Student *
Contact Information for Person Referring Student *
Referring Person's Relationship to Student *
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