Pre-registration - Teaching & Learning Center - Lakeland Community College

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Pre-registration form


Please complete the following information:
(Fields marked with * are required)
Email: *
Child's Name: *
Gender:	Male or Female
Birthdate: *
Age (years & months):
My child turns/ed 18mos on (give date):
My child turns/ed 3 years on (give date):
Parent's Names:
Address:

City:
State:
Zip:
Contact Phone: *
Home:
Cell:
Work:
Desired Enrollment Date:
Is your child a:	Toddler (18 mos-3 yrs) or Preschooler (3-5 yrs)
Child's previous school group experiences:
Does your child have any health problems that may be of concern?
OPTIONAL INFORMATION*
How did you hear about Lakeland's Teaching & Learning Center? (check all that apply)	Newspaper advertisement Radio advertisement Television advertisement Friend or family Lakeland employee News Release Mailing Poster or flyer on campus Electronic sign on Rt. 306 Lakeland cable network Email from Lakeland Link on Lakeland web site Link from another web site Internet search engine Other:
Please email me with updates for Teaching Learning Center. Lakeland may email me with general information.
*** This information helps Lakeland better communicate by measuring the results of our promotional efforts.**


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