Northeast Dubois Class Registration Signup Form

Lost River Career Cooperative Student Registration Form (Northeast Dubois)

Fill out the form carefully for registration
Student Name*

First NameMiddle NameLast Name
Gender*
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student E-mail*
Grade (19-20 school year)*
Mobile Number

Area CodePhone Number
Phone Number

Area CodePhone Number
What School do you attend?*
CTE Course I am requesting*
Hold the shift key and click to add more than one CTE course
Parent name

First NameLast Name
Parent Phone

Area CodePhone Number
Emergency Contact

First NameLast Name
Emergency Contact Phone

Area CodePhone Number
Medical information (Medical conditions, Medications, Allergies, Doctor etc)
Should be Empty: