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Kirkwood Linn Regional Center 2018-2019 Pre-Registration Form
This form does not guarantee admission but will help us to determine course offerings and availability. Students that complete the application, submit their test scores, and attend orientation will be given first priority. You'll be invited to attend a mandatory orientation in spring, at which time you'll learn more about other program logistics for Fall 2018-Spring 2019.
School confirmation code *
You will get this from your HS School Counselor. This confirms that the student identified on this form is eligible for college credit in high school options per the Senior Year Plus Regulations. Your school district agrees to make payment in accordance with our agreement.
Your answer
High School *
Please provide your Kirkwood student k number
If you have previously taken Kirkwood classes, or have already applied to Kirkwood, you have a k number assigned to you. If you are a new Kirkwood student, please remember to complete the College Credit in High School Application.
Your answer
Last Name *
As it is printed on your ID
Your answer
First Name *
As it is printed on your ID
Your answer
Address *
Your answer
City *
Your answer
Zip Code *
Your answer
HS Graduation Year *
Student Email Address *
Your answer
Parent/Guardian Email Address
Your answer
Phone Number *
(319) 555-1234
Your answer
Please list your cell phone provider. *
This will allow Kirkwood to text you information while you are attending Linn Regional.
Your answer
Date of Birth *
MM/DD/YYYY
Your answer
Do you have an IEP or 504 Plan at your high school? *
If you have an IEP/504 Plan at your High School will you be seeking special accommodations at Linn Regional?
Racial/Ethnic Information
The following are voluntary questions used for state & local reports. With which of the following group(s) do you identify?
Gender
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