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 Name Middle Name Last Name
Gender *
Birth Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

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

Area Code Phone Number
Phone Number

Area Code Phone 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 Name Last Name
Parent Phone

Area Code Phone Number
Emergency Contact

First Name Last Name
Emergency Contact Phone

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