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» Legacy Program Enrollment Form

Alumni Name(s):
Relationship to child (children):
UIU Graduation Year(s):
Address:
City:
State:
ZIP:
E-mail:
Telephone number:


Please complete a separate section for each child.
Note:If you want to enroll more than three children, please complete this form additional times as needed.

1. Child's name:
Date of Birth:
Child's Address (if different from above):
City:
State:
ZIP:
Anticipated High School Graduation Year:
2. Child's name:
Date of Birth:
Child's Address (if different from above):
City:
State:
ZIP:
Anticipated High School Graduation Year:
3. Child's name:
Date of Birth:
Child's Address (if different from above):
City:
State:
ZIP:
Anticipated High School Graduation Year:

Questions?

Joseph Moses
Development Officer/
Special Programs Coordinator
mosesj@uiu.edu
563-425-5374

 
 
 

Last Updated 11/8/07