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First Name*	M. I.	Last Name*
Mailing Address*
City*	State*	ZIP Code*
Phone*	Birth year (i.e. 1985) Gender Female Male How much education have you completed? Please select one of the following Still in high school Not finished high school High school graduate or equivalent Some college Certificate or Associate degree Bachelors degree or higher Are you enrolled at another school? Yes No Name: Location:
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If you're considering enrolling at Chemeketa, when would you like to begin? Term: Fall Winter Spring Summer Year:

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What field or subject area interests you: Please Select area of interest Accounting Aquarium Science Automotive Technology Building Inspection Technology Business Technology/Administrative Assistant Civil Technology/Survey Technology Computer Programming/Support Specialist Criminal Justice Dental Assisting Drafting Technology-CAD Early Childhood Education Electronics Technologies/Computer Electronics Emergency Medical Technology/Paramedic Fire Science Graphic Design Health Services Management/Medical Transcription Horticulture Hospitality Management Tourism & Travel Management Human Services/Addiction Studies/Social Services Integrated Circuit Mask Design ^C Juvenile Corrections Certificate Management Medical Office Assisting Network Technology Nursing Occupational Skills Training Paraeducator Certificate Professional-Technical Teacher Preparation Retail Management Speech Language Pathology Assistant Vineyard Management Visual Communications Welding Winemaking Winemarketing Agriculture Anthropology Art Biology/Botany/General Science/Zoology Business Administration Chemistry Chiropractic Computer Science Criminal Justice Dental Hygiene Design Economics Elementary Education Secondary Education Engineering English Foreign Languages Forest Management General Studies Geography Geology Health, Health Education History Hotel, Restaurant, and Resort Management Nutrition & Food Management Journalism Mathematics Nursing Transfer Nutrition & Food Management Philosophy Physical Education/Human Movement Studies Physics Political Science Pre-Law Pre-Professional (medicine, dentistry, veterinary medicine) Psychology Sociology Speech English as a Non-Native Language

Please send me an enrollment packet.

Please send me next term's schedule of classes.

I'd like a campus tour.
Campus tours are not available during weekends, holidays or college closure days. Please schedule at least three working days in advance.

Preferred date
Preferred time	Select Time 9 a.m. 9:30 a.m. 10 a.m. 10:30 a.m. 11 a.m. 11:30 a.m. Noon 12:30 p.m. 1 p.m. 1:30 p.m. 2 p.m. 2:30 p.m. 3 p.m. 3:30 p.m. 4 p.m.

We will e-mail you to confirm the campus tour date and time.

I would like to learn more about:
^{Please select up to five areas of interest from the following list.}

Paying for College Learn about available financial aid and scholarships that can help you pay for college. Tuition and Fees Quality education at a value price. Distance and Online Education We offer more than 260 college courses and professional workshops. Chemeketa's Campuses & Centers Different locations for your convenience. Transferring Credits Planning to transfer credits from another college to Chemeketa. Athletics A range of competitive sports for males and females. High School and GED Completion Various programs for those who don’t have a high school diploma.

Counseling and Advising Services Counselors and advisors are available to help identify courses you need for graduation and transfer. Registration Guidelines to register. Workforce Training We offer many services and classes to help you grow your business and educate your employees. Personal Enrichment Take a class just because you want to learn. Credit for Prior Learning Earn credit for what you already know. Student Life Add fun and friendships to your learning experience. Special Needs Advising, advocacy, personal help and equipment for those with learning, physical and psychiatric disabilities.

Additional requests or questions:

If you have additional requests or questions, we will respond to you via e-mail.

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Due to privacy concerns we ask that you do not include your SSN or any other confidential information when submitting this form.