Main Campus Visit Date
Friday May 3, 2024 Monday, May 6, 2024 Friday, May 10, 2024 Monday, May 13, 2024 Monday, May 20, 2024 Friday, May 24, 2024 Friday, May 31, 2024 Monday, June 3, 2024 Friday, July 19, 2024 Monday, July 22, 2024 Monday, July 29, 2024 Friday, Aug. 2, 2024 Monday, Aug. 5, 2024 Friday, Aug. 16, 2024 Monday, Aug. 19, 2024 Friday, Aug. 23, 2024 Monday. Aug. 26, 2024 Friday, Aug. 30, 2024

First Name

Last Name

Email

Phone

Phone Type
Cell Home Other Work

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Street Address

City

State/Province
Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon

Zip/Postal Code

Hotel Accommodations
Yes No By requesting a hotel, I acknowledge that I am at least 18 years of age or older.

Hotel Check-In Date

Hotel Check-Out Date

Hotel Room Type
Single Double

Number of Guests
Zero One Two Three

Guest Name 1

Guest 1
Palmer graduate?

Guest Name 2

Guest 2
Palmer graduate?

Guest Name 3

Guest 3
Palmer graduate?

Dietary Restrictions/ Food Allergies
Diabetic Gluten-Free Low Cholesterol / Low Fat Low Sodium Non-Lactose Nut or Peanut Allergies Vegetarian Other(s) Lunch is provided. Please select any dietary restrictions or food allergies. To select more than one, hold the 'Ctrl" key (PC) or 'Command' key (Mac) to do so.

Dietary Needs Other(s) Details

Media Consent
I give full consentI do not give full consent I hereby authorize and give full consent to Palmer College of Chiropractic to copyright, publish and/or use my image in photography or videos taken by Palmer College in which I may appear.

Comments
Any questions, concerns, needs or special accommodations?

Comments