IU Northwest Request for Information

Demographics

Legal First Name

Legal Last Name

Email

Cell Phone

I wish to opt in to receive SMS Messages from Indiana University

Yes

By checking this box, you are providing your express written consent that Indiana University may, directly or through third parties acting on its behalf, send marketing information regarding Indiana University and your continuing education, including texts, e-mail, and calls made using an automated dialing system to the number and email address that you provided above. Providing this consent is not required to obtain any good or service.

Would you like to provide your mailing address?

Yes

No

Mailing Address

Country

Street

City

Region

Postal Code

Semester to Begin

Type of Admission

Last Institution Attended

HIDDEN: Institution CEEB

In-Person or Online

Area of Interest

Campus [HIDDEN]

Northwest Stage [HIDDEN]

Unique ID [HIDDEN]

Do you want to provide parent/guardian information?

Yes

No

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Do we have permission to contact this parent/legal guardian?

Yes

No