Heart Saver CPR Program Registration

Apply for Term Beginning

Fall Spring Summer

Have you previously attended Lake Land College?
Yes No

*First Name

Middle Initial

*Last Name

Previous Name(s)

*Home Address

*City

*State
Select an option AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - WyomingD.C. - District of Columbia

*Zip Code
Zip Code format must match: 99999
*County

Home Phone (including area code)
Cell Phone format must match: 999-999-9999
Cell Phone (including area code)
Cell Phone format must match: 999-999-9999
*Email
Email format must match: email@address.com
Disclosure of information protected by privacy laws such as FERPA and GLBA is prohibited.

*Date of Birth


*Gender
Male Female Gender Unknown (assign to Male for federal reporting) Gender Unknown (assign to Female for federal reporting) Another Gender (assign to Male for federal reporting) Another Gender (assign to Female for federal reporting)

*Are you a parent?
Not a Parent (nor a pregnant individual) Single Parent (includes single pregnant individuals) Married Parent (includes married pregnant individuals)

*Are you Hispanic or Latino?
Yes Hispanic or Latino
No Hispanic or Latino

*Are you from one or more of the following racial groups? (Select all that apply)

	Asian
	American Indian or Alaska Native
	Black or African American
	White
	Native Hawaiian or Other Pacific Islander
	Choose Not to Respond

*Please identify your primary racial/ethnic group (Select one)

Asian
American Indian or Alaska Native
Black or African American
Hispanic or Latino
White
Native Hawaiian or Other Pacific Islander
Choose Not to Respond

*Are you in the United States on a Visa - Nonresident Alien?
Yes in the United States on a visa
Not in the United States on a visa

Provide Home Country of Origin

Professional License number for CE

*Last High School Attended

*City of Last High School Attended

*State of the Last High School Attended
Select an option AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - WyomingD.C. - District of Columbia

*Year graduated from high school or expected to graduate
Year graduated format must be a valid 4-digit year
Year received GED
Year received GED format must be a valid 4-digit year

List ALL colleges/universities attended or now attending write “none” if you have never attended a college/university
Name

City

State
Select an option AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - WyomingD.C. - District of Columbia


Name

City

State
Select an option AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - WyomingD.C. - District of Columbia


Name

City

State
Select an option AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - WyomingD.C. - District of Columbia

Highest Degree Earned
None/less than H.S. GED High School Diploma Certificate Associate Bachelor's Master's Doctoral First Professional Other Some College Unknown

Academic Program (for office use only)


Degree/Certificate Objective
Only complete one or several courses not pursuing a degree.

Transfer Intent
Do you plan to transfer to a 4 year college or university?
Yes No

Student Intent
Personal interest/self development not career oriented

Residency Status:
Have you resided in the Lake Land College District for at least the immediate past 30 days?
Yes No

If you recently moved (less than 30 days) into this community college district to establish permanent residency for reasons other than attending Lake Land College, please specify reason for move

Student Type
Are you currently enrolled full time at Eastern Illinois University?
Yes No

Are you enrolling in this course under the Illinois Department of Corrections and Lake Land College contractual agreement?
Yes No



Course(s) Registered

NDP.HRTS

Heart Saver CPR Registration

*Applicant Certification:

I understand that withholding information requested on this application, or giving false information, may make me ineligible for admission to the College or subject to dismissal. With this in mind, I certify that the above statements are correct and complete.

*What is the current 4-digit year? (ex. 2025)