Visit Request

Student's First Name *

Student's Last Name *

Student's Email *

Confirm Student's Email *

Home Phone

Student's Cell Phone *

Address *

Address 2

City *

State / Province / Region *

ZIP *

Country *

Date of Birth *

Name of Student's High School

High School Graduation Date

Scholarship and Areas of Interest at the Highland Campus (Choose up to 3)

Technical Programs (Located at the Technical Center in Atchison, Kansas) Optional: Only Choose if Interested in a Technical Program Automotive Collision Repair Automotive Technology Business Technology Computer Support Technology Diesel Technology Electrical Technology Engineering Graphics & Technologies HVAC & Plumbing Industrial Welding Technology LPN to RN Completion Medical Office Assistant Practical Nursing

Athletics Optional: Choose One Baseball Cheerleading Cross Country Dance ESports Football Men's Basketball Softball Track & Field Volleyball Women's Basketball Women's Soccer

Highland Campus Special Events *

Requested Date of Personalized Visit *

Other Comments

Does anyone in your party request physical accommodations on your visit? (We do quite a bit of walking on our campus tour.) If so, please state:

Date