Legal Name
Address
City, State, Zip
Work Phone Home Phone
Email
Date of Birth (MM/DD/YYYY)
Are you a United States citizen? Yes No If no, type of Visa:
Male Female
Please select your primary racial/ethnic group:
American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White Choose not to respond
Please indicate the highest degree you have earned:
High School/GED Certificate Associate Bachelor's Master's Doctoral None
Course/Workshop Title:
Cost of course/workshop:
Payment Method
Check (make payabe to LLCC, mail to the address below or bring to your first day of class. Credit Card (Discover, MasterCard or Visa) - please call 217.786.2434 to make payment by phone
After submitting your registration you will receive an email confirming your registration and you will be redirected to the Green Center website.
Please mail your payment to Julie Bates, Green Center at Lincoln Land Community College, 5250 Shepherd Road, Springfield, IL 62794-9256 or bring it to the course on the day of the event.
For more information, contact Julie Bates at 217.786.2434 or julie.bates@llcc.edu
