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Collaborative Course Form

This form must be filled out for each providing institution.

Example: LRSC student, taking an online course from University of North Dakota and Williston State College, must fill out this from twice with course information for both institutions.  For more information about being a collaborative student. Please see, LRSC Admissions and click on Collaborative Students Tab.
 
* Indicated Required Field

Student Contact Information

(Q1)First Name*
(Q2)Middle Name
(Q3)Last Name*
(Q4)Student ID#*
(Q5)Date of Birth (MM/DD/YYYY)*
(Q6)Current Mailing Address*
(Q7)City*
(Q8)State or Province*
(Q9)County
(Q10)Zip Code*
(Q11)Country, if other than US
(Q12)Primary Phone Number*
(Q13)Secondary Phone Number
(Q14)Campus Email Address*

Collaborative Status Information

(Q15)Do you now or have you lived in North Dakota?*
Answer Q16-Q18 if you answered Yes to Q15.
(Q16)If yes, list the years (1998-present or 2010-2011)
(Q17)If you lived in ND less than one year, in what state did you most recently reside?
(Q18)For how many years did you reside in that state? Continue on Q21.
Answer Q19 - Q20 if you answered No to Q15.|You are not currently a ND Resident or have never lived in ND.
(Q19)In what state are you a resident?
(Q20)List years you have lived in your current state (ex. 2005-present).

Collaborative courses taken from another institution

(Q21)Institution where you will receive your degree?*
(Q22)Are you participating in any third party arrangements to pay your tuition and fees (i.e. military tuition assistance, voc rehab, job service, etc.)?*
(Q23)Institution you want to take a collaborative course from (provider institution). You need to complete this Collaborative Course Form for each institution.*
(Q24)Semester you wish to enroll for?*
Fill Out Collaborative Course Information for each course taken from the delivery institution you selected in Q24
Collaborative Course Information #1
Class Number*
Subject and Catalog Number (ex. ENGL 110)
Course Title (ex. College Composition I)*
Semester Hours (Credit) (ex. 3)
Delivery method:*
Collaborative Course Information #2
Class Number
Subject and Catalog Number (ex. ENGL 110)
Course Title (ex. College Composition I)
Semester Hours (Credit) (ex. 3)
Delivery Method:
Collaborative Course Information #3
Class Number
Subject and Catalog Number (ex. ENGL 110)
Course Title (ex. College Composition I)
Semester Hours (Credit) (ex. 3)
Delivery Method:
Collaborative Course Information #4
Class Number
Subject and Catalog Number (ex. ENGL 110)
Course Title (ex. College Composition I)
Semester Hours (Credit) (ex. 3)
Delivery Method:

Agreement

In lieu of a signature: 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.