Info Request for Madras Campus at COCC

Fields marked with a red asterisk (*) are required.

Contact Information

Legal First Name

Last Name

Chosen First Name (To be used on COCC communications)

Date of Birth

Mailing Address

Country

Street

City

Region

Postal Code

Phone

Mobile Phone

Can we send you occasional text messages regarding important dates and event reminders?

Yes

No

Reply STOP to unsubscribe. Message and data rates may apply.

Email

Personal Email Address

Education Information

Are you currently in High School?

Yes

No

High School Graduation Month and Year

High School Name

Please search again and click on your school name in the High School Name List.

I plan to enroll:

Interests

I'd like to enter contact information for my parent or guardian:

Yes

No

Relationship Type

First Name

Last Name

Email Address