Enrollment

Tell us about the student we'll be supporting.

Student Name *

Student Last Name *

Student Email *

Student Phone *

Mailing Address

Current Year in School

Local Address

Student Residence Type

Parent/Guardian Name *

Parent Email *

Parent Phone Number *

Address at School

Please list a contact other than the primary parent / guardian.

Full Name *

Relationship to Student *

Phone Number *

Email Address

Help us understand where this student may need support.

Membership Plan Selected *

Crisis

Connection

Comprehensive

Primary Areas of Interest / Support Needed

How Did You Hear About Us?

Additional Comment

Type your full legal name to sign *

Full Name *

This acts as your electronic signature on the College Circle membership agreement. In production this step is handled by our e-signature provider.

I agree to the Membership Terms and Privacy Policy, and authorize College Circle to charge my membership fee on a recurring basis.

Payment is processed securely via Stripe on the next step

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Let's Set Up Your Circle of Support