Southeastern Community College

Alumni Association Membership Form

* denotes optional information.

    Personal Information

     First Name:

*   Middle Initial:

     Last Name:

     Social Security Number:

*   Previous/Maiden Name:

    Mailing Address

     Street:

     City:

     State:

     Zip Code:

    Contact Information

     Home Phone Number: Please include your area code.

*   Work Phone Number: Please include your area code.

     E-mail Address:

    Dates Attended SCC:

           

    Campus Attended:

    West Burlington     Keokuk     Both     Other

    Major(s)

     

    Diplomas/Certificates Awarded

    AA     AS     AAS     Certificate     None

    Other

*   Occupation:

*   Hobbies:

* I wish to participate in the Nursing Alumni Chapter

* I wish to help establish another program chapter


NOTE: Annual dues received on or after October 1 of each year will be effective through December 31 of the next year.

NOTE TO SCC STUDENTS: 50% discount on LIFETIME FEES available after completion of first term and up to 90 days from date of SCC graduation!

Alumni Enrollment Options

    Alumnus Individual (for successful completion of at least one credit class)

   Annual     $ 10.00

   Lifetime   $100.00

   Lifetime   $ 50.00   (SCC student discount - see above)

    Associate Individual (for a non-alumnus individual)

   Annual     $ 15.00

   Lifetime   $150.00

    Alumni Couple (for two married alumni)

   Annual     $ 16.00

   Lifetime   $160.00

    Associate Business (for businesses/agencies)

   Annual    $ 200.00

   Lifetime  $2000.00

*  Other Contributions

     Alumni Scholarships: $

     Nursing Chapter Scholarship: $

     Outstanding Faculty Award: $

     Distinguished Alumni Award: $

     Other: $

     Please Specify "Other"

If you wish to learn more about the SCCAA Nursing Alumni Chapter before joining the SCC Alumni Association, please click here www.sccnursingalumni.org

    Total Amount Due:

PLEASE MAIL YOUR REMITTANCE TO:

   SCC Alumni Association

   1500 W. Agency Road - P.O. Box 180

   West Burlington, IA 52655

It is the policy of Southeastern Community College to provide equal educational and employment opportunities and not to illegally discriminate on the basis of gender, race, national origin, religion, age, marital status, or disability in its educational programs, activities or employment and personnel practices.

 

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