Continuing Education Online Application (non-credit)

Submitting the registration form does not guarantee a place in the class. In the case that a class is full or more information is requested, Iowa Lakes will inform you through email or by telephone.

Indicates a Required Field

Course #1:

Course #1 Name:

Course #2:

Course #2 Name:

Course #3:

Course #3 Name:

Last Name:

First Name:

Middle Initial:

Street Address:

City:

State:

Zip:

Home Phone:

Day Phone:

Alternate Phone (if available):

Date of Birth:

Social Security Number:

Gender:

Male
Female

Ethnic Background (optional - please check one):

Asian or Pacific Islander	American Indian or Alaskan Native
Black Non-Hispanic	Hispanic
White Non-Hispanic	Other

Email Address:

Professional License # (if applicable):

Type of License:

Payment Option I plan to use::

Call 1-800-252-5664 or 712-362-7231 with credit or debit card number (VISA, MasterCard or Discover)	Mail check to Iowa Lakes Continuing Education(include student’s name & course number)
Stop in at any Iowa Lakes business office	Payment will be made by a sponsoring party. (If so, the following information must be provided)

Name of Sponsoring Party:

Sponsoring party street address:

Sponsoring party city:

Sponsoring party state:

Sponsoring party zip code:

Verification Code:

Please enter the letters and numbers you
see on the image into the text box below.

Registration will be confirmed by email or phone call. Please contact us at 1-800-252-5664 or 712-362-7231 if you have not received a reply within three working days of submitting this form. Your place in class cannot be guaranteed until payment is received. Thank you!

Iowa Lakes Community College
Campuses in Algona, Emmetsburg,
Estherville, Spencer and Spirit Lake.

Equal Opportunity Statement

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