Student Health Services

Online Registration

Fill out all of the fields below. After submitting your information, you will receive a confirmation code via text message. Enter the code on this site to complete the registration process.

** Field is required

** First Name

** Last Name

** Date of Birth (MM/DD/YYYY)

** Email Address (will become your web account user name)

Confirm Email Address

** Address

** City

** State

** Zip Code (The zip code of your local residence)

** Mobile Phone #

** Gender

Male Female Other

Extra Details

** Ethnicity

** Race

2nd Race (optional)

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