Southeastern Community College

Family Monday Registration

* denotes required information.

* Event Date:

* Campus you would like to visit: Keokuk    West Burlington

* First Name:

* Middle Initial: enter 'X' if no middle initial

* Last Name:

* Birthdate:

* E-Mail Address:

* Confirm E-Mail Address:

* Address:

* City:

* State:

* Zip:

* Cell Phone:  Please include area code

* Major/Area of Interest:

* High School Name:

* High School Graduation Year:

* How did you hear about this event?

* Family Member:

* Family Member Name(s):

Yes, I would like to visit with a faculty member

Yes, I would like to tour West Burlington campus housing