Program and Activities Council Interest Form

Please complete the contact information portion of this form first, then indicate which PAC roles interest you the most. Our advisor will be in contact with you shortly to invite you to one of our meetings and to let you know more about helping out as a member of PAC.

Name: *

Please enter your first and last name.

Student ID: *

Please enter your 7-digit student ID number listed on your OneCard.

Home phone: *

Please enter your home phone number in the following format: (608) 246-6576

Cell phone:

Please enter your cell phone number in the following format: (608) 246-6576

Street Address: *

Enter your street address (Example: 3550 Anderson St.)

City: *

Zip Code: *

Enter your 5-digit zip code

E-mail address: *

Enter the e-mail address you would like us to use to contact you

Primary campus:

Please list the campus where you attend most of your classes

Field of study:

What program are you attending at Madison College?

Credits enrolled in:

How many credits are you enrolled in this semester?

PAC staff roles: *

Please indicate which PAC staff roles interest you the most.

Last Modified: August 25, 2010

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Program and Activities Council Interest Form

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