Yes! Send me more information about the Defiance College ASD Affinity Program!

If you would like to receive more 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.


First Name   Last Name
Mailing Address
City State Zip/Postal Code
Home phone     My Email  
Cell Phone          

Parent Name  
Parent Phone Number  
Parent EMail  

Gender   Female   Male    
Date of Birth      
Graduation Year      
Planned Start Term  
Major Preference:
Choice #1
Choice #2

If an education major was selected above, choose a teaching field or a licensure.

Collegiate Activities
In which activities do you 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
Vocal/Choral Music DC Pride Social Work Assn.
Wrestling (club) Pep Band  

Intercollegiate Activities
In which intercollegiate activities do you plan to participate?
Baseball Basketball Track
Softball Cheerleading Football
Volleyball Soccer Tennis
Cross-Country Golf