Student Referral Form
Do you know a student who might benefit from the Cottey College Experience? Fill in her contact information below and we will add her to our mailing list and communication outreach. Thank you!
Student Name and Contact Information
First Name
Last Name
Email Address
Street Address
City
State or Province
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Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
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District of Columbia
Florida
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Idaho
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Iowa
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Louisiana
Maine
Manitoba
Marianna Islands
Marshall Islands
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Minor Outlaying Islands
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
Newfoundland and Labrador
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Yukon
Zip Code
Country
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United States
Afghanistan- Islamic State of
Albania
Algeria
American Samoa
Andorra- Principality of
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaidjan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia-Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia- Kingdom of
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo- The Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
Former Czechoslovakia
Former USSR
France
France (European Territory)
French Guyana
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe (French)
Guam (USA)
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast (Cote D'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea (North)
Korea (South)
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique (French)
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldavia
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
Neutral Zone
New Caledonia (French)
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Polynesia (French)
Portugal
Puerto Rico
Qatar
Reunion (French)
Romania
Russian Federation
Rwanda
S. Georgia & S. Sandwich Isls.
Saint Helena
Saint Kitts & Nevis Anguilla
Saint Lucia
Saint Pierre and Miquelon
Saint Tome (Sao Tome) and Principe
Saint Vincent & Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Tadjikistan
Taiwan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Unknown
Uruguay
USA Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (USA)
Wallis and Futuna Islands
Western Sahara
Yemen
Zaire
Zambia
Zimbabwe
Program Information
Anticipated Start Term
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Fall
Spring
Anticipated Start Year
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2020
2021
2022
2023
2024
Student Type
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Transfer
Freshman
International
Re-admit
Unknown/Other
Academic Interest
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African American Studies
Accounting
Advertising
Agriculture
Anatomy
Anthropology
Architecture
Art
Animal Science
Astronomy
Biochemistry
Business Education
Biology
Business Law
Botany
Business Administration
Chemistry
Criminal Justice
Classical Studies
Communication
Computer Science
Dental Hygiene
Dance
Drama
Economics
Education
English
Engineering
Entomology
Environmental Studies
Fashion Merchandising
Fine Arts
Foreign Languages
Food Services
Forestry
French
Forensic Science
Geography
Geology
German
Graphic Arts
Greek
Health Education
Higher Education
History
Home Economics
Horticulture
Humanities
Interior Design
International Relations
Italian
Journalism
Latin American Studies
Latin
Law
Law Enforcement
Liberal Arts
Literature
Mathematics
Marine Biology
Mass Communication
Medicine
Meterology
Management
Microbiology
Military Science
Marketing
Music Education
Music Literature
Nursing Science
Occupational Therapy
Pathology
Physical Education
Performing Arts
Pharmaceutical Science
Philosophy
Photography
Physics
Physiology & Biophysics
Physical Therapy
Political Science
Portuguese
Pre-Dentistry
Pre-Law
Pre-Med
Psychology
Public Administration
Reading
Real Estate
Recreation
Rehabilitation Education
Religion
Russian
Sciences
Secondary Education
Sociology
Social Work
Speech & Pathology
Spanish
Special Education
Sports Medicine
Statistics
Theater
Travel & Tourism
Undecided
Veterinary Science
Western Civilization
World Literature
Women's Studies
Zoology
What school does she currently attend?
Choose Unknown School if no match
Optional Information
Birthdate (mm/dd/yyyy)
Home Phone
Cell Phone
Athletic Interest
Please select...
Basketball
Cross Country
eSports
Golf
Softball
Track
Volleyball
Your Contact Information
Full Name
Mailing Address
Preferred Phone
Preferred Email
Are you a Cottey Alumna?
Yes
No
What is your Class Year?
P.E.O. Chapter
Please select...
A
AA
AB
AC
AD
AE
AF
AG
AH
AI
AJ
AK
AL
AM
AN
AO
AP
AQ
AR
AS
AT
AU
AV
AW
AX
AY
AZ
B
BA
BB
BC
BD
BE
BF
BG
BH
BI
BJ
BK
BL
BM
BN
BO
BP
BQ
BR
BS
BT
BU
BV
BW
BX
BY
BZ
C
CA
CB
CC
CD
CE
CF
CG
CH
CI
CJ
CK
CL
CM
CN
CO
CP
CQ
CR
CS
CT
CU
CV
CW
CX
CY
CZ
D
DA
DB
DC
DD
DE
DF
DG
DH
DI
DJ
DK
DL
DM
DN
DO
DP
DQ
DR
DS
DT
DU
DV
DW
DX
DY
DZ
E
EA
EB
EC
ED
EE
EF
EG
EH
EI
EJ
EK
EL
EM
EN
EO
EP
EQ
ER
ES
ET
EU
EV
EW
EX
EY
EZ
F
FA
FB
FC
FD
FE
FF
FG
FH
FI
FJ
FK
FL
FM
FN
FO
FP
FQ
FR
FS
FT
FU
FV
FW
FX
FY
FZ
FZ-GR
G
GA
GB
GC
GD
GE
GF
GG
GH
GI
GJ
GK
GL
GM
GN
GO
GP
GQ
GR
GS
GT
GU
GV
GW
GX
GY
GZ
H
HA
HB
HC
HD
HE
HF
HG
HH
HI
HJ
HK
HL
HM
HN
HO
HP
HQ
HR
HS
HT
HU
HV
HW
HX
HY
HZ
I
IA
IB
IC
ID
IE
IF
IG
IH
II
IJ
IK
IL
IM
IN
IO
IP
IQ
IR
IS
IT
IU
IV
IW
IX
IY
IZ
J
JA
JB
JC
JD
JE
JF
JG
JH
JI
JJ
JK
JL
JM
JN
JO
JP
JQ
JR
JS
JT
JU
JV
JW
JX
JY
JZ
K
KA
KB
KC
KD
KE
KF
KG
KH
KI
KJ
KK
KL
KM
KN
KO
KP
KQ
KR
KS
KT
KU
KV
KW
KX
KY
KZ
L
LA
LB
LC
LD
LE
LF
LG
LH
LI
LJ
LK
LL
LM
LN
LO
LP
LQ
LR
LS
LT
LU
LV
LW
LX
LY
LZ
M
MA
MB
MC
MD
ME
MF
MG
MH
MI
MJ
MK
ML
MM
MN
MO
MP
MQ
MR
MS
MT
MU
MV
MW
MX
MY
MZ
N
NA
NB
NC
ND
NE
NF
NG
NH
NI
NJ
NK
NL
NM
NN
NO
NP
NQ
NR
NS
NT
NU
NV
NW
NX
NY
NZ
O
OA
OB
OC
OD
OE
OF
OG
OH
OI
OJ
OK
OL
OM
ON
OO
OP
OQ
OR
OS
OT
OU
OV
OW
OX
OY
OZ
P
PA
PB
PC
PD
PE
PF
PG
PH
PI
PJ
PK
PL
PM
PN
PO
PP
PQ
PR
PS
PT
PU
PV
PW
PX
PY
PZ
Q
QA
QB
QC
QD
QE
QF
QG
QH
QI
QJ
QK
QL
QM
QN
QO
QP
QQ
QR
QS
QT
QU
QV
QW
QX
QY
QZ
R
RA
RB
RC
RD
RE
RF
RG
RH
RI
RJ
RK
RL
RM
RN
RO
RP
RQ
RR
RS
RT
RU
RV
RW
RX
RY
RZ
S
SA
SB
SC
SD
SE
SF
SG
SH
SI
SJ
SK
SL
SM
SN
SO
SP
SQ
SR
SS
ST
SU
SV
SW
SX
SY
SZ
T
TA
TB
TC
TD
TE
TF
TG
TH
TI
TJ
TK
TL
TM
TN
TO
TP
TQ
TR
TS
TT
TU
TV
TW
TX
TY
TZ
U
UA
UB
UC
UD
UE
UF
UG
UH
UI
UJ
UK
UL
UM
UN
UO
UP
UQ
UR
US
UT
UU
UV
UW
UX
UY
UZ
V
VA
VB
VC
VD
VE
VF
VG
VH
VI
VJ
VK
VL
VM
VN
VO
VP
VQ
VR
VS
VT
VU
VV
VW
VX
VY
VZ
W
WA
WB
WC
WD
WE
WF
WG
WH
WI
WJ
WK
WL
WM
WN
WO
WP
WQ
WR
WS
WT
WU
WV
WW
WX
WY
WZ
X
XA
XB
XC
XD
XE
XF
XG
XH
XI
XJ
XK
XL
XM
XN
XO
XP
XQ
XR
XS
XT
XU
XV
XW
XX
XY
XZ
Y
YA
YB
YC
YD
YE
YF
YG
YH
YI
YJ
YK
YL
YM
YN
YO
YP
YQ
YR
YS
YT
YU
YV
YW
YX
YY
YZ
Z
ZA
ZB
ZC
ZD
ZE
ZF
ZG
ZH
ZI
ZJ
ZK
ZL
ZM
ZN
ZO
ZP
ZQ
ZR
ZS
ZT
ZU
ZV
ZW
ZX
ZY
ZZ
P.E.O. State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Canada
How do you know this student?
Please select...
I know her personally.
I met her at a college fair.
Someone else recommended her to me.
Additional Comments
Contact Information
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