Self Advocacy Packet

First Name

Please enter your first name

Last Name

Please enter your last name

Email

Phone

Street Line 1

Street Line 2

City/Town/Municipality

State

Postal Code

I am a

Select one

Parent

Student

Counselor

Student's highest education level

Some high school

High school diploma

Some college

Program of interest

Select one

Enrollment Year and Term of Interest

(examples: Fall 2023, Bridge Semester 2022)

How did you first learn about Landmark College?

(examples: Google search, Facebook, ad on website, Pandora radio spot, news article)

Questions or Comments

As we make every effort to comply with the EU's GDPR, please answer the following questions:

Are you currently in or a resident of an EU country

Yes

No

May we contact you about additional programs and services?

Yes

No

Contact Preference

(select all that apply)

Email

Phone

Text

Social Media

Fill out this form to download your Student Self-Advocacy Booklet.