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Collaborative Course Form

Lake Region State College students must fill out this form for each
providing institution.

Please see, Collaborative Students under Admissions for more information
prior to filling out the following form.

 
* Indicated Required Field

Collaborative Student Form

Full Name*
Student ID #*
Date of Birth (MM/DD/YYYY)*
Permanent Address (street, city, state, zip)*
City*
State*
Zip Code*
Years of Residency*
Current Address (if different from permanent address)
Country, if NOT United States
Phone Number*
Campus Email*
Other Email

Collaborative Course Information

Provider Institution*: College you wish to take a collaborative course from
Year*
Term*

Collaborative Request #1

Indicate the course information you wish to add or drop from the provider institution.
Add/Drop
Subject and Catalog Number (ex. ENGL 110)*
Class Number*
Course Title (ex. College Composition I)*
Credit Hours (ex. 3)*
Delivery Method*
Reason for adding or dropping the course?

Collaborative Request #2

Add/Drop
Subject and Catalog Number (ex. ENGL 110)*
Class Number*
Course Title (ex. College Composition I)*
Credit Hours (ex. 3)*
Delivery Method*
Reason for adding or dropping the course?

Collaborative Request #3

Add/Drop
Subject and Catalog Number (ex. ENGL 110)*
Class Number*
Course Title (ex. College Composition I)*
Credit Hours (ex. 3)*
Delivery Method*
Reason for adding or dropping the course?

Collaborative Request #4

Add/Drop
Subject and Catalog Number (ex. ENGL 110)*
Class Number*
Course Title (ex. College Composition I)*
Credit Hours (ex. 3)*
Delivery Method*
Reason for adding or dropping the course?

Agreement

I have read and understand all criteria and deadlines as presented on this form. I certify that all statements in this registration are true to the best of my knowledge. I also authorize Lake Region State College to e-mail my Student ID to the provider institution I have chosen. This is just a request and I understand that my registration is not completed until I receive confirmation from the provider institution.
 

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