Non-Degree Seeking Student Registration Form

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Some content may be updated based on selection

Non-Degree Seeking Student Registration Form

Please complete all of the fields listed below and click on the Submit button when completed. Please contact our Welcome Center at registration@lakeshore.edu if you have any questions.

Student Information

Lakeshore Student ID:

Legal First Name:

Legal Last Name:

Preferred Name:

Former Name:

Date of Birth:

Sex Assigned at Birth:

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 Email Address:

I am a resident of (county):

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

High School (if homeschoold, enter homeschool):

High School Graduation Year:

Class Information

Term:

Year:

Class Number:

Class Title:

Term:

Year:

Class Number:

Class Title:

Term:

Year:

Class Number:

Class Title:

In the event that any of the sections identified above reach capacity, do you consent to enrollment in another section of the same course with the same delivery method?

I plan to transfer my class(es) to another college/university for credit in another program.

Which program are you completing class(es) toward?

Federal Demographics

Are you Hispanic or Latino?

Select any other groups that apply to you:

American Indian / Alaskan Native

Native Hawaiian or Pacific Islander

Black or African American

White

Asian

Other

Work Status at Enrollment:

Single Parent:

Limited English Proficiency:

Economically Disadvantaged:

Disability:

Highest Credential:

Highest Grade:

Displaced Homemaker:

Academically Disadvantaged:

Veteran:

Highest Degree Earned by Parent:

Homeless:

Foster Care Youth:

Age 16-24 Parent in Military/Active Duty:

Initials

I herby confirm that the information provided in this registration form is true and accurate. I understand that submission of this form constitutes a request to register me in the selected course(s).

Initials

I understand that I am responsible for the payment of related tuition and fees according to the college payment policy. I acknowledge that the applicable registration fees are applied to my account when I am registered in the selected course(s) and I am aware of my payment options and payment due dates.

Statement of Understanding

By submitting this form, I agree to comply with all related terms, conditions, and deadlines communicated by Lakeshore College.

My signature below confirms that I understand and agree to the above. I also understand that typing my name in the box provivded below is the equivalent of placing my signature on a document.

Student Signature

Date

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 Vice President of Student Services 920.693.1858, Tanya.Boman@lakeshore.edu / Benefits/Human Resources Manager (staff/others) 920.693.1136, Debbie.Sosnosky@lakeshore.edu. 1290 North Avenue, Cleveland, WI 53015. TTY 711 https://lakeshore.edu/equal-opportunity-statement

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