RegForm

Long-term Class Student Info/Data Form

Fill out this form to register for the Long-term class.

Fill this out as completely as possible. This information will be used to contact you during the time you are enrolled in the class. All blanks with a * are required. You can't submit the form untill all the required blanks are filled in.
Be sure that your contact information is correct, and that you check your email often.
BE SURE TO CHECK THE VLC AT LEAST DAILY for important information.

Today's Date*

MonthDayYear

Full Name*

First, Middle Initial, Last

Contact Information

Use the area below to enter in your contact information. This is where/how you will be contacted for questions, announcements, schedule/venue changes, etc. Be sure that you can be reached at these contacts.

Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

You can reach me here during work.

Home Phone*

Format: (000) 000-0000.

You can reach me here during work.

Work Phone*

Format: (000) 000-0000.

You can reach me here during work.

Cell Phone*

Format: (000) 000-0000.

You can reach me here during work.

Other Contact Info*

Notes on Contact Information:

As you learned in class, in order to take exams, see your grades, etc., you will also have to set up a user account and enroll in the class on the VLC (Virtual Learning Center). During this sign-up process, you will need to provide an email address.

This email address, and the VLC are the "go to" spots--they are the first place to check for class announcements; news; class changes/cancellations due to weather or other reasons; venue changes; etc. The VLC is your primary contact with the instuctor. Be sure that you check the VLC often--especially before class each session-- for possible last-minute changes (cancellation, time and/or venue change, etc)!

Class Information

Check which Long-term Class you are registering for

LT100 (Wastewater Treatment Plant Operation & Maintenance)LT200 (Wastewater Collection Systems)

Beginning Date of Class*

MonthDayYear

Class Location*

City

Employer Information

Enter your employer and certification information here.

Employer*

Who are you employed by?

Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Your Title*

Your job position

Your Current Certification Level*

Click all that apply. (Ctrl+Left-click selects/deselects multiple items)

Your Desired Certification Level*

Click all that apply. (Ctrl+Left-click selects/deselects multiple items)

Notes or comments

Enter any additional notes, comments, directions or information here, if needed.