Join the VAN

Enrollment Form

First name

M.I.

Last name

Nickname

Maiden name, if appropriate

Spouse's full name

Mailing address

City

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