Workforce & Professional Development Registration Form

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LEHIGH CARBON COMMUNITY COLLEGE
4525 Education Park Drive * Schnecksville, PA 18078-2502

Phone: 610-799-1171 * Fax: 610-799-1173

Workforce & Noncredit Registration Form

SECTION 1: Student Information

Please print your name exactly as it appears on legal documents. LCCC will generate a student identification number (LCCC ID Number) that you will use to access your student information.

First Name:

Last Name:

Preferred First Name:

LCCC ID Number (If known):

Last 4 of Social Security Number:

Date of Birth:

Email:

Preferred Phone #:

Street Address:

City:

State:

Zip Code:

Your responses to the following questions regarding gender and ethnicity are voluntary and will be treated as confidential.

Legal Sex

Gender Designation

Ethnicity

SECTION 2: Course Information

Year:

Term:

How many classes will you be registering for?

CRN #

Course Subject/Number (i.e. NCJA 050)

Course Start Date

SECTION 3: Signature and Certification

by submitting this form:

• I agree to abide by the policies and regulations of Lehigh Carbon Community College.
• The information given above is complete and accurate to the best of my knowledge.

• I will be responsible to pay all costs associated with the course(s).
• I understand this registration form is for non-credit coursework only.

INTERNAL OFFICE USE ONLY

L #

Comments

Registration Signature

Please read the Disclosure / Consent before you sign your form electronically.

Typing your name exactly as it appears below signifies you are completing this form using an electronic signature. By signing electronically, you are certifying that you have read and understand the Disclosure/Consent and agree to electronically sign. You also agree to receive required disclosures or other communications related to this transaction electronically.

To continue with the electronic signature process, please enter your first name in the first field, and your last name in the second field. Your name must match the names displayed in the dialog. Next, click the "Sign Electronically" button to save your information and submit your electronic signature.

Please review your name and try again

Opting out of electronic signature and printing voids the form! If you must opt out of electronic signature, please contact Registration and Student Records for assistance at registrar@mymail.lccc.edu

I have read the opt out instructions provided and understand my responsibilities associated with my opt out decision.

Opt out and print

Date

Paid in Full

Payment Plan Set Up

Business Office Approval

Please read the Disclosure / Consent before you sign your form electronically.

Please review your name and try again

I have read the opt out instructions provided and understand my responsibilities associated with my opt out decision.

Opt out and print

Date

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