Personal Information

     First Name:

*   Middle Initial:

     Last Name:

     Social Security Number:

*   Previous/Maiden Name:

    Mailing Address

     Street:

     City:

     State:

     Zip Code:

    Contact Information

     Home Phone Number: Please include your area code.

*   Work Phone Number: Please include your area code.

     E-mail Address:

    Dates Attended SCC:

      Start Didn't Attend 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 Before 1980       Finish Didn't Graduate 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980

    Campus Attended:

    West Burlington     Keokuk     Both     Other

    Major(s)

    Diplomas/Certificates Awarded

    AA     AS     AAS     Certificate     None

    Other

*   Occupation:

*   Hobbies:

* I wish to participate in the Nursing Alumni Chapter

* I wish to help establish another program chapter

NOTE: Annual dues received on or after October 1 of each year will be effective through December 31 of the next year.

NOTE TO SCC STUDENTS: 50% discount on LIFETIME FEES available after completion of first term and up to 90 days from date of SCC graduation!

Alumni Enrollment Options

    Alumnus Individual (for successful completion of at least one credit class)

   Annual     $ 10.00

   Lifetime   $100.00

   Lifetime   $ 50.00   (SCC student discount - see above)

    Associate Individual (for a non-alumnus individual)

   Annual     $ 15.00

   Lifetime   $150.00

    Alumni Couple (for two married alumni)

   Annual     $ 16.00

   Lifetime   $160.00

    Associate Business (for businesses/agencies)

   Annual    $ 200.00

   Lifetime  $2000.00

*  Other Contributions

     Alumni Scholarships: $

     Nursing Chapter Scholarship: $

     Outstanding Faculty Award: $

     Distinguished Alumni Award: $

     Other: $

     Please Specify "Other"

If you wish to learn more about the SCCAA Nursing Alumni Chapter before joining the SCC Alumni Association, please click here www.sccnursingalumni.org

    Total Amount Due:

PLEASE MAIL YOUR REMITTANCE TO:

   SCC Alumni Association

   1500 W. Agency Road - P.O. Box 180

   West Burlington, IA 52655