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* 1. Personal Information:

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* 2. Date of Birth:

Date

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* 3. Social Security Number

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* 4. I've taken classes at LCOOU in the past

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* 5. Address:

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* 6. Resident of (check one):

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* 7. County in which you reside:

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* 8. What is your gender identity?

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* 9. Race:

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* 10. What is your ethnicity? (Please select all that apply.)

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* 11. What is the highest level of education you have completed?

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* 12. Please identify site preference.

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* 13. By checking this box you are registering for the Emergency Medical Responder CEU course.
Once registered for the course, you have created a liability with LCOOU and promise to pay for the course at the rate of $500.00.

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* 14. Youth Registration: With parent/guardian permission, students age 16 or younger can attend LCOOU courses scheduled outside students normal school hours. **Some courses may have minimum age prerequisites.
Electronic Signature of Parent/guardian

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* 15. Sponsored Registration: If an agency or employer has agreed to pay your tution, complete the section below and attach written authorization.

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