Student Group Membership Application

School Name *

Address 1 *

Address 2

Address 3

City

State / Province

Zip / Postal Code

Country *

How did you hear about CCIH? *

If you're applying as a student group, please describe the group, its purpose and the name of the faculty sponsor.

Who, if any, are your local and international partners?

Primary Contact Information. Please complete the fields below for your school's primary point of contact.

First Name *

Last Name *

Title *

Email *

Phone *

Timeout Warning