Campus Visit Date

First Name

Last Name

Phone
(Numbers only, no hyphens or spaces.)

Phone Type

By providing your cell phone, you authorize occasional text messages regarding prospective student events and updates. If you do not wish to receive text messages, please check the box below to opt-out.
I DO NOT want to receive text messages.

Country

State/Province

Street Address

City

Zip/Postal Code

Number of Guests

Guest's Name

Is your guest a Palmer College graduate?
YesNo

Guest's Name

Is your guest a Palmer College graduate?
YesNo

Will you be joining us for lunch?

Media 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