Spouse ID and Wellness Center Access Request

Student Last Name

Student First Name (Do not abbreviate)

Student ND ID (Ex: 902XXXXXX)

Student ID Expiration Date (on front of ID card)

Has your spouse previously been affiliated to the University of Notre Dame under a different name?

Yes

No

Spouse Last Name

Spouse First Name

What was the name?

Spouse ND ID (if they currently have one)

Spouse's Date of Birth

Spouse's Last 4 digits of SSN

Spouse's Email Address

Spouse's Gender

Female

Male

Mailing Address

Country

Street

City

Region

Postal Code

Spouses' Phone Number

Marriage Certificate

Do you have children?

Yes

No

Child 1 - First Name

Child 1 - Last Name

Child 1 - Date of Birth

Child 1 - Gender

Female

Male

Child 1 - Last 4 digits of SSN

Child 1 - Birth Certificate

Do you have a 2nd child?

Yes

No

Child 2 - First Name

Child 2 - Last Name

Child 2 - Date of Birth

Child 2 - Gender

Female

Male

Child 2 - Last 4 digits of SSN

Child 2 - Birth Certificate

Do you have a 3rd child?

Yes

No

Child 3 - First Name

Child 3 - Last Name

Child 3 - Date of Birth

Child 3 - Gender

Female

Male

Child 3 - Last 4 digits of SSN

Child 3 - Birth Certificate

Do you have a 4th child?

Yes

No

Child 4 - First Name

Child 4 - Last Name

Child 4 - Date of Birth

Child 4 - Gender

Female

Male

Child 4 - Last 4 digits of SSN

Child 4 - Birth Certificate

Do you have a 5th child?

Yes

No

Child 5 - First Name

Child 5 - Last Name

Child 5 - Date of Birth

Female

Male

Child 5 - Last 4 digits of SSN

Child 5 - Birth Certificate