EMR Registration Form
Continuing Education Course (Non-Credit)

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1. Personal Information:

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2. Date of Birth: (Required.)

Date

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3. Social Security Number

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4. I've taken classes at LCOOU in the past

Yes

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5. Address: (Required.)

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Cell or Phone Number *

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6. Resident of (check one):

Township

Village

City

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7. County in which you reside:

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8. What is your gender identity?

Female

Male

Non-binary

Prefer not to answer

Not specified above, please specify

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9. Race:

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple ethnicity / Other (please specify)

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10. What is your ethnicity? (Please select all that apply.)

Hispanic/Latino

Non-Hispanic/Latino

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11. What is the highest level of education you have completed?

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12. Please identify site preference.

Hayward Site

Red Cliff Site

Gordon

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13. By checking this box you are registering for the Emergency Medical Responder CEU course.
Once registered for the course, you have created a liability with LCOOU and promise to pay for the course at the rate of $500.00.

Emergency Medical Responder CEU Course

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14. Youth Registration: With parent/guardian permission, students age 16 or younger can attend LCOOU courses scheduled outside students normal school hours. **Some courses may have minimum age prerequisites.
Electronic Signature of Parent/guardian

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15. Sponsored Registration: If an agency or employer has agreed to pay your tution, complete the section below and attach written authorization.

Name of Business/Agency

EMS/Fire Sponsor

I authorize LCOOU to forward information regarding the completion of this course to the sponsor listed above-Electronic Student Signature.

EMR Registration FormContinuing Education Course (Non-Credit)

Question Title

* 1. Personal Information:

Question Title

* 2. Date of Birth: (Required.)

Question Title

* 3. Social Security Number

Question Title

* 4. I've taken classes at LCOOU in the past

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* 5. Address: (Required.)

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* 6. Resident of (check one):

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* 7. County in which you reside:

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* 8. What is your gender identity?

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* 9. Race:

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* 10. What is your ethnicity? (Please select all that apply.)

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* 11. What is the highest level of education you have completed?

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* 12. Please identify site preference.

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* 13. By checking this box you are registering for the Emergency Medical Responder CEU course. Once registered for the course, you have created a liability with LCOOU and promise to pay for the course at the rate of $500.00.

Question Title

* 14. Youth Registration: With parent/guardian permission, students age 16 or younger can attend LCOOU courses scheduled outside students normal school hours. **Some courses may have minimum age prerequisites. Electronic Signature of Parent/guardian

Question Title

* 15. Sponsored Registration: If an agency or employer has agreed to pay your tution, complete the section below and attach written authorization.

EMR Registration Form
Continuing Education Course (Non-Credit)

1. Personal Information:

2. Date of Birth: (Required.)

3. Social Security Number

4. I've taken classes at LCOOU in the past

5. Address: (Required.)

6. Resident of (check one):

7. County in which you reside:

8. What is your gender identity?

9. Race:

10. What is your ethnicity? (Please select all that apply.)

11. What is the highest level of education you have completed?

12. Please identify site preference.

13. By checking this box you are registering for the Emergency Medical Responder CEU course.
Once registered for the course, you have created a liability with LCOOU and promise to pay for the course at the rate of $500.00.

14. Youth Registration: With parent/guardian permission, students age 16 or younger can attend LCOOU courses scheduled outside students normal school hours. **Some courses may have minimum age prerequisites.
Electronic Signature of Parent/guardian

15. Sponsored Registration: If an agency or employer has agreed to pay your tution, complete the section below and attach written authorization.