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Winter 2013 Campus Visit Day
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Registration
Campus Visit Day Registration: Spencer
Spencer Campus: Wednesday, February 27, 2013
Indicates a Required Field
First Name:
Last Name:
Gender:
Male
Female
Date of Birth:
Email Address:
Phone Number:
Cell phone number:
Street Address:
City:
State:
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces - Americas
Armed Forces - Europe/Africa/Canada
Armed Forces - Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
High School name:
Expected graduation date:
Program of Interest (Spencer):
Accounting Specialist
Business Administration & Management
Health Care Administration
Massage Therapy
Medical Assistant
Medical Assistant Specialist
Medical Office Technology
Pharmacy Technician
Surgical Technology
Transfer Degree
Persons attending:
I will attend by myself
I will attend with my parent(s)
Do you plan to take the COMPASS test?:
Yes
No
Do you have any special needs to be considered?:
No
Yes
If yes for special needs, please describe:
Other activities (check all that apply):
Band/Choir
Honors Program
Intramurals
Newspaper
Student Ambassadors
Student Senate
Trio-SSS
Athletic Interests:
Baseball
Men’s Basketball
Women’s Basketball
Cheerleading
Cross Country (M&W)
Dance
Golf (M&W)
Soccer (M&W)
Softball
Swimming and Diving (M&W)
Volleyball
Wrestling
Verification Code:
If you are not sure what the words are, enter your best guess.