Transcripted Credit Pre-Registration Form

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Transcripted Credit Pre-Registration Form

Please complete all of the fields listed below and click on the Submit button when completed. Please contact Lakeshore's Dual Credit Office at DualCredit@gotoltc.edu if you have any questions.

Student Information

Legal First Name:

Legal Last Name:

PreferredName:

Pronouns:

Date of Birth:

Sex Assigned at Birth:

Please Provide your Social Security Number.

If you have not been issued a Social Security Number (SSN), enter 999-99-9999 as a placeholder that will allow you to submit the Pre-Registration form. Lakeshore College will use your SSN as a personal identifier in order to create your student account.

Address:

City

State:

ZIP Code:

Personal Phone Number:

Personal or School Email Address:

I am a resident of (county):

I live in the (city/town/village) of:

High School:

High School Graduation Year:

Class Information

Class Number:

Class Title:

Federal Demographics

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:

Highest Degree Earned by Parent:

Disability:

Homeless:

Highest Credential:

Foster Care Youth:

Highest Grade Completed:

Age 16-24 Parent in Military/Active Duty:

Statement of Understanding

Initials

I understand that I will be enrolled into the course listed above through Lakeshore Technical College for transcripted credit.

Intials

I understand that I will be held to Lakeshore’s enrollment and grading policies. By clicking Submit Form I agree with the statements above.

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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