Course Registration

Course Registration Application

Fill in the application below.

New Students - Complete all sections of the application.
Current Students - Complete the Personal Information and Course Information sections only.

Personal Information
Name:
Email:

Address:

City:

State:

Zip:

Country:

Date of Birth: (month/date/year)

Gender: Male Female

Social Security Number:

Day Phone:

Evening Phone:

Fax:

Local Religious Affiliation:

Address:

City: State: Zip:

Phone Number:

Pastor/Rabbi/Leader Name:

List any relatives who are presently attending or have previously attended LaMeD Academy or AIHLS.

Name:

Relationship:

Name:

Relationship:

Educational Information (Required for degree credit)

High School Name:

Year Graduated:

High School Address:

High School City: State: Zip:

Colleges/Universities/Other Schools Attended -

Name: Degree/Credits Earned:

Address:

City: State: Zip:

Name: Degree/Credits Earned:

Address:

City: State: Zip:

Name: Degree/Credits Earned:

Address:

City: State: Zip:

General Information

How did you hear about us:

newspaper

religious affiliation (church, synagogue, mosque,...)

radio

referred by

web search engine

Course Information

I am interested in attending but not . Bachelor Degree credit.

I am registering for a (an): course.

Course(s) I am registering for:

I acknowledge that all information provided in this application is correct, I have read the official policy statement and (if taking an online course) I have read the Online Course Expectations.

Electronic Signature:

Date: