Palmer College of Chiropractic, Admissions, Campus Visit Registration Form

D.C. Program

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Palmer College of Chiropractic

Admissions

Campus Visit Registration

Please fill out all sections of this form. After you are finished,
press the "Submit to Admissions Department" button at the bottom of the page.

*mandatory field (if you don't have an e-mail please enter NA)

Hotel:		Yes No **Prospective students who do not officially sign-in at the campus visit will be held responsible for the payment of their hotel accommodations.
Date of Visit:		Monday Friday Saturday Campus Visit, March 10, 2007 Destination Success, Saturday, March 31, 2007
		*Have you previously participated in a campus visit?
Student Name:
*Last:
*First:
Middle:
Birth date:		MM/DD/YYYY
*Address:
*City:
*State:
*Zip code:
*Telephone:
*E-mail address:
*Home State:
*School Currently Attending:
*School City:
*School State:
Term Start Date:		(MM/YY) Applied Not Applied
Hotel Information:
Check-in date: Type none if hotel accommodations are not needed Check-out date: Type none if hotel accommodations are not needed
Number of Persons:
Room Needed:		King Two Queen Beds

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Palmer College of Chiropractic
1000 Brady Street, Davenport, IA 52803-5287
Phone: (800) 722-3648 or (563) 884-5656 | Fax: (563) 884-5414
e-mail: pcadmit@palmer.edu