QSA Student Group/Club Member Registration

QSA Group Name*

Name*

First Name

Initial (optional)

Last Name

Student ID*

8 digital number found in the lower left corner on the front of your QCC TigerCard

Email*

I understand that by submitting this application, I am agreeing to join this student group as a member. I am also agreeing to allow the student group to contact me via email.

Signature

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Use your mouse or finger to draw your signature above