Senior Day Registration Form - Keokuk Campus
Name
*
First Name
Middle Initial
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Confirm Email Address
*
example@example.com
Mobile Phone Number
*
-
Area Code
Phone Number
High School
*
Graduation Year
*
Program of Interest
*
Associate of Arts
Associate of Science
Advanced Technology, Construction & Welding
Agriculture Studies
Automotive Technology
Business Management & Administration
Education
Health Professions
IT & Multimedia
Industrial Maintenance
Undecided
Other
Which day would you like to attend?
*
September 28 (Tuesday)
October 26 (Tuesday)
November 12 (Friday)
November 30 (Tuesday)
Will you be bringing a guest?
*
Yes
No
Guest Name
First Name
Last Name
Guest Email
example@example.com
Please check any additional opportunities to add to your Visit Day
Meet with faculty one on one
Meet with financial aid
Take/schedule placement testing (testing not available on Friday Visit Days)
T-Shirt Size?
*
How did you here about SCC Visit Day?
*
Submit
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