Alumni Student Referral Form


If you would like a student to receive information about Defiance College, please complete the form below. Please note when filling out this form: Use the Tab button to switch from question to question, or use your mouse. Hitting the return key will submit the form.


Defiance College admits students regardless of race, color, religion, gender, age, national and ethnic origin, disability, or sexual orientation.

First Name   Middle Name
Last Name   Preferred Name
Maiden Name      
City State Zip/Postal Code
County Country  
Gender Female Male        
STUDENT telephone:  
STUDENT email:  
High School name:  
H.S. Address:  
If known...        
Graduation Year:    
Please include your name and address.
Alum Name:
Alum Address:
Alum Email:
The STUDENT would be interested in coursework offered through the following programs:
Full-time Student Graduate Studies Weekend College
Intended College Major(s):
If known, please select the major(s) that the STUDENT would be interested in. If you are unsure, please indicate "Undecided" as the first preference.
Choice #1
Choice #2
Collegiate Activities
If known, which activities would the STUDENT plan to participate in college?
American Marketing Assn. Yearbook Black Action Student Assn.
Religious Activities Ecology Club Criminal Justice Society
Community Service Student Senate Campus Activities Board
Fraternities or Sororities  Newspaper Student in Free Enterprise
Psychological Assn.   Social Work Assn.
Intercollegiate Activities
If known, which intercollegiate activities would the STUDENT plan to participate?
Baseball Golf Softball
Basketball Tennis Swimming and Diving
Cross-Country Track & Field Volleyball
Football Soccer  
Please send information about financial aid and family financial planning.