Business Office Form

Student Information
Date*
MM slash DD slash YYYY
Name*
First Middle Last
Are you a United States Citizen?*
- Yes
- No
Ethnicity (optional)
- White
- African American
- Native American
- Hispanic
This information is only used for the Department of Education.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone
Email
Date of Birth*
MM slash DD slash YYYY
I am a*
- Freshmen
- Sophomore
- Junior
- Senior

Family Information
Father's Name*
First Last
Is your father's address same as student's?*
- Yes
- No
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Father's Phone*
Father's Email*
Mother's Name*
First Last
Is your mother's address same as student's?*
- Yes
- No
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mother's Phone*
Mother's Email*

Promissory Note
Please review the paragraph below. By signing, you and/or your parents or guardians agree to the provisions stated. This agreement is valid for the duration of your time at Thomas More College of Liberal Arts. All students under the age of 24 years must have a parent signature on the Promissory Note.
Name of Student*
First Last
Are you under the age of 24 years?*
- Yes
- No
I and/or my parent(s) or guardian(s), have received and read The Thomas More College Business Office Handbook. I/We agree to pay my/our tuition account bills with The Thomas More College of Liberal Arts, Six Manchester Street, Merrimack, NH 03054 according to the guidelines in The Thomas More College Business Office Handbook. I/We understand that if payment is not received according to the Business Office Handbook, I/We will be notified that this account may be reviewed for collection. Should this account be sent to the collection agency, I/We understand that all finance charges, collection and legal fees will be my/our responsibility.*
Student Signature
Parent Signature*

Medical Consent Form
Are you under the age of 24 years?*
- Yes
- No
Name of Student*
First Last
Date of Birth*
MM slash DD slash YYYY
In the event that the above named individual, who is attending The Thomas More College of Liberal Arts, Six Manchester Street, Merrimack, NH 03054,is in need of emergency medical treatment and we/I cannot be reached, the signature(s) below give permission to the physician(s) selected by the College to hospitalize, secure proper medical treatment, order routine tests, which could include blood work, x-rays or any related tests,and/or order injections, anesthesia, and/or surgical procedures for the student named above. We/I give permission for the responsible personnel of Thomas More College to release to the hospital emergency personnel pertinent information regarding any current health problems or allergies, insurance information, and the name(s) address, and telephone number for emergency notification. We/I release the College, its staff, and its employees from any and all liability arising from any medical procedure. It is understood that the College and/or physician are required by state law to report positive results of certain laboratory tests to the public health agencies.
In the event that the above named individual, who is attending The Thomas More College of Liberal Arts, Six Manchester Street, Merrimack, NH 03054,is in need of emergency medical treatment and I/we cannot be reached, the signature(s) below give permission to the physician(s) selected by the College to hospitalize, secure proper medical treatment, order routine tests, which could include blood work, X-rays or any related tests,and/or order injections, anesthesia, and/or surgical procedures for the student named above. I/We give permission for the responsible personnel of Thomas More College to release to the hospital emergency personnel pertinent information regarding any current health problems or allergies, insurance information, and the name(s) address, and telephone number for emergency notification. I/We release the College, its staff, and its employees from any and all liability arising from any medical procedure. It is understood that the College and/or physician are required by state law to report positive results of certain laboratory tests to the public health agencies.*
Student Signature
Parent Signature*

Medical Insurance Information
Name of Insurance Provider*
Plan Type*
- HMO
- PPO
- Self-Pay
Subscriber's Name*
First Last
Policy Number*
Group Number*
Insurance carrier's phone number*
Primary physician*
First Last
Primary physician's phone number*
Physician's Office Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Upload a copy of the front and back of your health insurance card.
Insurance Card - Front*
Accepted file types: pdf, jpg, Max. file size: 50 MB.
Insurance Card - Back*
Accepted file types: pdf, jpg, Max. file size: 50 MB.

Name*
First Last
Email*

Phone
In addition to the Eblast, please send me (optional):
- Information Packet by Mail
- The Communitas Newsletter
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How did you hear about Thomas More College?*
I am a...
Year of High School Graduation*
Would you like to make a Donation?
- Yes.
- No, thank you. Another time.
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Gift Amount
Gift Type*
- One Time Gift
- Monthly Gift
Total
$0.00
Phone
This field is for validation purposes and should be left unchanged.

All students are required to read the Business Office Handbook and then complete the Business Office Form before the start of the 2020-2021 Academic Year.

Business Office Handbook 2020-2021

Business Office Form

Step 1 of 6

Student Information

Family Information

Promissory Note

Medical Consent Form

Medical Insurance Information

Upload a copy of the front and back of your health insurance card.