Business Office Form

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*
Date Format: 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.
Insurance Card - Back*
Accepted file types: pdf, jpg.

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.