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Use This Form for Continuing Education Only Please Print
Lake Superior College
Emergency Response Training Center
11501 Hwy 23
Duluth, MN 55808
Phone (218) 723-1074
Fax completed form to Continuing Education/Customized Training (218) 733-1094
Semester you are registering for (circle one)
Fall/Spring/Summer Year: 20_______
Have you ever taken a credit class at LSC? ___ Yes ___ No
Name_________________________________________________________________
Last First MI Birth Name
Street Address__________________________________________________________
City__________________ State_____ Zip Code__________
Home Phone___________ Work Phone___________
Email Address________________
SS#____________________
(Providing your social security number is voluntary. Classes may be tax deductible under Hope Scholarship and Life-long Learning tax laws. Your social security number must be provided in order to claim either of these deductions.)
Resident of MN? ___ Yes ___ No
County_______________
Primary Ethnic Background (select one only):
¨ Black or African American
¨ Hispanic or Latino
¨ Asian
¨ American Indian or Alaskan Native
¨ White
¨ Native Hawaiian or Pacific Islander
Secondary Ethnic Background (s) (select all that apply):
¨ Black or African American
¨ Hispanic or Latino
¨ Asian
¨ American Indian or Alaskan Native
¨ White
¨ Native Hawaiian or Pacific Islander
Method of Payment
Check # _________
Please bill my : ___ Visa ___ Master Card
Account #__________________________
Expiration Date__________
Signature__________________________________
Fees Must Accompany the Registration Form
This form is for students not planning to pursue a diploma or degree. A student planning to pursue a diploma or degree must complete the formal admissions process prior to registering for courses.
Course Registration Information
Dept./Course#
Sec. #
Course Title Non-Credit Courses
Hours
CEU Credits Tuition/Fees
Total Hours/Credits/Fees
Please print this form out and either carry, mail or fax it to Lake Superior College to register for classes. You can not submit this form online. Back to Continuing Ed Home Page
Adult Special Registration Form
Page 2 PAYMENT SOURCE Cash Check Credit Card Agency Funding
(Please Circle) Other (specify)____________
I undertand that I am responsible for all charges incurred once I register at Lake Superior College.
I understand that I am responsible for making changes to my schedule in accordance with LSC add/drop/withdrawal and refund policies.
I understand that tuition is always due the business day before the term begins.
I understand that I may be subject to late fees.
I understand that I must contact the LSC Student Payment Office to make payment arrangements.
I understand that I may be required to make a payment before starting any term.
I understand that if I have an unpaid balance, no further enrollment at Lake Superior College will be permitted.
I understand that any unpaid balance will be turned over to a collection agency.
I understand that I am fully responsible for any collection costs and fees.
I understand that this is a legal binding agreement.
I have read this agreement and I agree to the terms specified.
I understand that if I wish to pursue a degree at LSC, I must complete the admission process.
Signature_____________________________ Date_______________
