Member Info Form

Campus Compact Member Information

Please complete and forward this to the Office of Campus Compact of Oregon. Please call 503-406-3575 with questions. Thank you!

College/University Name ______

Address______

City, State, Zip______

Main Phone #______

Date Joined ______Today’s Date ______

Number of Full-Time Equivalent Undergraduate Students______

For community colleges this is degree enrolled students only

PresidentPresident’s Staff Contact

Salutation (Mr., Ms., Dr.) ______Salutation (Mr., Ms., Dr.) ______

Name ______Name ______

Title ______Title ______

Office ______Office ______

Campus Address ______Campus Address______

______

Telephone: ______Telephone: ______

Fax: ______Fax: ______

E-Mail:______E-Mail: ______

Does the president want to receive ORCC’s Add this person to ORCC’s monthly

monthly e-newsletter? Yes Noe-newsletter recipient list? Yes No

Community Service ContactFaculty Service Learning Contact

Salutation (Mr., Ms., Dr.) ______Salutation (Mr., Ms., Dr.) ______

Name ______Name ______

Title ______Title ______

Office ______Office ______

Campus Address ______Campus Address ______

______

Telephone: ______Telephone: ______

Fax: ______Fax: ______

E-Mail: ______E-Mail: ______

Add this person to e-newsletter list? Yes NoAdd this person to e-newsletter list? Yes No

Chief Academic Officer ContactChief Diversity/Equity/Inclusion Officer

Salutation (Mr., Ms., Dr.) ______Salutation (Mr., Ms., Dr.) ______

Name ______Name ______

Title ______Title ______

Office ______Office ______

Campus Address ______Campus Address ______

______

Telephone: ______Telephone: ______

Fax: ______Fax: ______

E-Mail: ______E-Mail: ______

Add this person to e-newsletter list? Yes NoAdd this person to e-newsletter list? Yes No

Government Relations ContactPress/Public Information Contact

Salutation (Mr., Ms., Dr.) ______Salutation (Mr., Ms., Dr.) ______

Name ______Name ______

Title ______Title ______

Office ______Office ______

Campus Address ______Campus Address ______

______

Telephone: ______Telephone: ______

Fax: ______Fax: ______

E-Mail: ______E-Mail: ______

Add this person to e-newsletter list? Yes NoAdd this person to e-newsletter list? Yes No

Student Affairs/Services ContactStudent Leadership Contact (if applicable)

Salutation (Mr., Ms., Dr.) ______Salutation (Mr., Ms., Dr.) ______

Name ______Name ______

Title ______Title ______

Office ______Office ______

Campus Address ______Campus Address ______

______

Telephone: ______Telephone: ______

Fax: ______Fax: ______

E-Mail: ______E-Mail: ______

Add this person to e-newsletter list? Yes NoAdd this person to e-newsletter list? Yes No

Institutional Research ContactGrants Office Contact

Salutation (Mr., Ms., Dr.) ______Salutation (Mr., Ms., Dr.) ______

Name ______Name ______

Title ______Title ______

Office ______Office ______

Campus Address ______Campus Address ______

______

Telephone: ______Telephone: ______

Fax: ______Fax: ______

Add this person to e-newsletter list? Yes NoAdd this person to e-newsletter list? Yes No

Cooperative Education ContactLiteracy/Mentoring Program Contact

Salutation (Mr., Ms., Dr.) ______Salutation (Mr., Mrs., Dr.) ______

Name ______Name ______

Title ______Title ______

Office ______Office ______

Campus Address ______Campus Address ______

______

Telephone: ______Telephone: ______

Fax: ______Fax: ______

Add this person to e-newsletter list? Yes NoAdd this person to e-newsletter list? Yes No

Thank You!

Campus Compact of Oregon▪ 620 SW 5th Avenue, Ste. 910 Portland, OR▪ 97204

503-406-3575▪