Office of Registration and Records
University of Wisconsin Stout
Change of Race/Ethnic Code Form
This form allows students to change their race or ethnicity from what is on file to a different
race/ethnicity if the race/ethnicity on file is incorrect or the student now identifies differently.
Registration and Records
109 Bowman Hall
Menomonie, WI 54751
Student Information
First Name:
Last Name:
Student ID#:
Current Ethnicity:
New Ethnic Code – Please Check All that Apply
African American or Black
Laotian
Puerto Rican
American Indian
Mexican,
Mexican American,
Or Chicano/a
Vietnamese
Cambodian
Other Asian
I Choose Not to Respond
Cuban
Other Hispanic or
Latino/a
(Specify Tribal Affiliation)
Hawaiian/Pacific Islander
Other
Hmong
(Specify)
Signature:
Date:
Office Use Only
Date Processed:
White or Caucasian
Initials:
Registration and Records Office
109 Bowman Hall
Menomonie, WI 54751‐0790
(715) 232‐2121 – Phone
(715) 232‐2436 – Fax
registrar@uwstout.edu