QMC Student Interest Form

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please provide contact information if you are interested in your student joining the Quinebaug Middle College learning community. Information collected will remain confidential and destroyed after the recruitment season. Reach out to our Guidance Counselor, Melissa Jacobs, with questions or concerns (mjacobs@eastconn.org or 860-932-4100). Thank you!

Parent First Name: *

Parent Last Name: *

Email: *

Cellphone Number: *

Why do you want your son/daughter to attend QMC? *

Student First Name: *

Student Last Name: *

Student's preferred gender pronoun(s)? *

He/him

She/her

They/them

Scholar's Interested Pathway *

Liberal Arts and Sciences: Education, Business, Humanities, Law, etc.

Allied Health: Nursing, Medicine, Medical Record, Lab Technician, Physical Therapist, etc.

Advanced Manufacturing: Robotics, Computer Science, Engineering, Manufacturing, etc.

Are you interested in attending our Prospective Student Night? *

Yes

Maybe

Additional information: *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of EASTCONN.

Does this form look suspicious? Report

Forms