Class Registration - 4 - 2018

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Some content may be updated based on selection

Class Registration

Student I.D. No. (8 digits)

Date of Birth:

Social Security No.

Employer Code:

(if applicable)

First Name

Middle Name

Last Name

Former Name

Gender

Home Address (Street, P.O.)

City

State

ZIP Code

Home Phone Number

Cell Phone Number

Other Phone Number

Home Email Address

Other Email Address

Place of Employment and Address

City

State

ZIP Code

Place of Employment or Place Where you Volunteer Service and Address

City

State

ZIP Code

The following information is for state and federal reporting and is confidential.

Are you Hispanic or Latino?

Select any other groups that apply to you:

American Indian or Alaskan Native

White

Native Hawaiian or Other Pacific Islander

Black or African American

Asian

Other

Work Status at Enrollment:

Displaced Homemaker:

Single Parent:

Academically Disadvantaged:

Limited English Proficiency:

Veteran:

Economically Disadvantaged:

First Generation Student:

Disability:

Homeless:

Highest Credential Received:

Foster Care Youth:

Highest Grade Completed:

Age 16-24 with Parent in Military/Active Duty

Last High School Attended and State

Date You Will or Did Graduate From High School

I am a legal resident of: County

City / Town / Village

School District

Catalog Number

5-Digit Class Number

Class Title

Start Date

Credits

Third Party Billing Agreement Information

The Billing agreement information must be submitted along with your registration. Lakeshore College will invoice the Company/Agency and payment is due upon receipt. If you are not eligible for Company/Agency funding, you will need to register by phone. Please call 1.888.GO.TO.LTC (1.888.468.6582), Ext. 1366.

Company Name

Date of Agreement

Billing Address

City

State

ZIP Code

Company Phone Number

Company Purchase Order Number

Authorizing Company Official

Company Offiicial's Email:

Lakeshore College does not discriminate against protected classes, including but not limited to race, color, national origin, religion, sex, or gender – including sexual orientation, gender identity, gender expression, disability or age in employment, admissions, or its programs or activities. To handle inquiries regarding Lakeshore's nondiscrimination policies, contact the Educational Support Services Manager (students) 920.693.1120, nicole.yang@gotoltc.edu / Executive Director of Human Resources (staff/others) 920.693.1158, marissa.holst@gotoltc.edu. 1290 North Avenue, Cleveland, WI 53015. TTY 711 gotoltc.edu/equal-opportunity-statement

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