Lyndon Institute
Registration Adult Education

INFORMATION: PLEASE PRINT

Name:_______________________________________________________
Address: ________________________________  City:________________  State:______   Zip:___________
Town of Residence:_____________________________________________
Day Phone #:__________________________________________________
Evening Phone #:_______________________________________________
Email address:_________________________________________________
Fax #:______________________________
Date of Birth:_________________________
Gender: _____Female   ______Male
Referred by: _________________________

Special Populations:
________Single Parent  __________ESL (limited English proficiency)   ___________Disability

Age Ranges:
Under 19 ____  19-35_____  35-55_____  56-______

Course Interest________________________________
Method of Payment_____________________________  Date of Payment_________________
Name of Employer Paying________________________  Personal Payment by______________
Semester: Fall 2007_______  Spring 2008______

Education:
No HS Diploma or GED____  HS Diploma or ADP_____  GED______  Some College, No Degree______
Associates Degree_____  Bachelors Degree_______

Race/Ethnic:
Alaskan Native____  American Indian___  African American___  Asian___  Hawaiian___  Hispanic___ 
Pacific Islander____  White____  Other____

No. in Household:  1  2  3  4  5  6  7  8  +

Main Reason for Enrolling: Circle One
Obtain Employment   Upgrade Employment   Obtain Credentials   Pursue Higher Education   Personal Goal

Refund Policy:
No refunds will be made one week prior to class beginning. 
Refunds will be made if the Adult Education Class is cancelled.

Signature______________________________________  Date:_________________________________