First name
M.I.
Last name
Nickname
Maiden name, if appropriate
Spouse's full name
Mailing address
City
State AE APO Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip
Country
Preferred phone number
Alternate phone number
Email address *
Re-enter email address *
Valparaiso University graduation date (undergraduate), if appropriate
Undergraduate major(s) at Valpo
Graduate degree/university, if any
Current employer or graduate school
Current title or position
Would you like to be a VAN Liaison with a high school near you? Please list high school and town.
Comments or suggestions
