Student First Name*:
Student Last Name*:
Class/Year:
Mother's Information
Title: Mrs.         Ms.         Dr.         Rev.         Other
    If other, please specify:
Mother's First Name:
Middle Name:
Mother's Last Name:
Mother is an alumna of Wagner College?       Yes         No        
Class/Year:
Nickname:
Mother's Maiden Name:
Marital Status:
Spouse/Significant Other:
Number of Children:
Preferred address for correspondence:       Home         Employment/Business        
Home Address and Phone
Address:
City: State:
Zip: Country:
Phone: Cellular Phone:
Fax: Email:
Employment/Business Information
Job Title:
Occupation:
Company Name:
Is your mother's employer a matching gift company?       Yes         No        
Matching gift forms can be obtained from your employer's human resources office.
Business
Address:
City: State:
Zip: Country:
Phone: Cellular Phone:
Fax: Email:
Mother interested in becoming an active member of the Parent Association?     Yes       No

Father's Information
Title: Mr.         Dr.         Rev.         Other
   If other, please specify:
Suffix: Sr.         Jr.         II         III         Other
   If other, please specify:
Father's First Name:
Middle Name:
Father's Last Name:
Father is an alumna of Wagner College?       Yes         No        
Class/Year:
Nickname:
Marital Status:
Spouse/Significant Other:
Number of Children:
Preferred address for correspondence:       Home         Employment/Business        
Home Address and Phone
Address:
City: State:
Zip: Country:
Phone: Cellular Phone:
Fax: Email:
Employment/Business Information
Job Title:
Occupation:
Company Name:
Is your father's employer a matching gift company?       Yes         No        
Matching gift forms can be obtained from your employer's human resources office.
Business
Address:
City: State:
Zip: Country:
Phone: Cellular Phone:
Fax: Email:
Father interested in becoming an active member of the Parent Association?     Yes       No

Paternal Grandmother's Information       (i.e., Your Father's Mother)

Title: Mrs.         Ms.         Dr.         Rev.         Other
   If other, please specify:
Paternal Grandmother's
First Name:
Middle Name:
Paternal Grandmother's
Last Name:
Paternal Grandmother is an alumna of Wagner College?       Yes         No        
Class/Year:
Nickname:
Paternal Grandmother's
Maiden Name:
Marital Status:
Spouse/Significant
Other:
Number of Children:
Preferred address for correspondence:       Home         Employment/Business        
Home Address and Phone
Address:
City: State:
Zip: Country:
Phone: Cellular Phone:
Fax: Email:
Seasonal Address and Phone
Start Date:
End Date:
Address:
City: State:
Zip: Country:
Phone: Cellular Phone:
Fax: Email:
Employment/Business Information - Please fill out even if your paternal gandmother is retired
Job Title:
Occupation:
Company Name:
Is her employer a matching gift company?       Yes         No        
Matching gift forms can be obtained from your employer's human resources office.
Business
Address:
City: State:
Zip: Country:
Phone: Cellular Phone:
Fax: Email: