STUDENT RECORD

Intake Date

First Name*

Middle Name

Last Name (Legal Last Name)*

Birthdate*

Gender*

Male

Female

Address Line 1*

Address Line 2

Zip Code*

City*

Country*

State*

Home phone

Mobile phone*

Work phone

Email address*

Permission to receive text message notifications from LVCC. Msg & data rates may apply. *

Yes

No

Are you Hispanic/Latino?*

Yes

No

Country of birth? *

Race?*

Highest Ed. Level Compl. on Entry:*

Employment Status*

Do you have barriers to employment?*

Yes

No

Choose one or more if Yes:*

Do you have school-age children in grades PreK-12?*

Yes

No

Choose one or more if Yes:*

Welcome to LVCC Student Registration. Thank you for joining us!