First Name: Last Name: Student ID #

Mailing Address: Apt. #
City: Zip:

Home phone:    Cell phone:

KSU Email Address:

Personal Email Address:

Please Select the Classification that best describes you as a student:

Freshman Sophomore Junior Senior Graduate Student Faculty/Staff Alumni

Degree Major:

How did you learn about ALSO?

Reason for joining ALSO (check all that apply)

Networking Opportunities Socializing Advocacy Campus & Resource Information

Other:

Would you be willing to help with a committee in the interests of Advocacy, Publicity, or Fundraising?
Yes No

Are there any services that you would like to see be offered that would be beneficial to you and other adult learners?