Fall Term 2020 LBCC Registration Request Form
This form will complete a registration request for a Parenting Education class. These forms are entered in the order they are received. A confirmation will be sent once the registration is complete to the email address provided on this form. In the event the class is full, we will notify you and offer alternatives if available. this form is for non-credit classes only. If you would like to take a credit version please call. You can also register yourself through WebRunner using Single Sign-On, or if you have questions, please call 541-917-4884 for more information. This form or WebRunner are the fastest way to register for Parenting Education classes.
Today's Date:
MM
/
DD
/
YYYY
Strengthening Rural Families Partner Class
The class you are registering for is a partnership class between Linn-Benton Community College and Strengthening Rural Families. You will be registered in this class at LBCC. Strengthening Rural Families will be taking payment for this class. As a partnership class, your contact information (name, email and telephone number) will be shared with Strengthening Rural Families.
LBCC PARTNER ORGANIZATION RELEASE (Both boxes must be checked to be enrolled) *
Required
Providing your social security number is voluntary. If you provide it, the college will use your Social Security number for keeping records, doing research, aggregate reporting, extending credit and collecting debts. Your Social Security number will not be given to the general public or any other entity outside of LBCC. If you choose not to provide your Social Security number, you will not be denied any rights as a student. Please read the statement with the registration information in your class schedule which describes how your number will be used. Providing your Social Security number means that you consent to use of the number in the manner described. See ADMINISTRATIVE RULE NO: 7040-03 for more information.
ID Number (referred to as your "X" number) or Social Security Number (see above statement). Continue to next question if student ID is unknown or you choose not to provide your Social Security Number.
Birth date (of adult registering for class) *
MM
/
DD
/
YYYY
Gender (optional)
Clear selection
Name: First, Middle, Last *
Maiden name or previous name used. Skip if does not apply to you.
Have you lived in Oregon or a border state for 90 days prior to the start of the term? *
Are you a U.S. Citizen or Resident Alien? (Optional)
Clear selection
If no, indicate type of Visa: (Optional)
Address (street or P.O. box), City, State, Zip: *
County of residence:
Cell phone number:
Home phone number:
Email address you will use for class: *
LBCC is required by the Federal Government to ask your race, Veteran status and ethnicity. Providing this information optional.
What is your race? Mark one or more. (Optional)
Are you a Veteran? (Optional)
Clear selection
What is your ethnicity? (Optional)
Clear selection
Students requiring accommodations contact Center for Accessibility Resources at 541-917-4789 or cfar@linnbenton.edu
Choose the non-credit course(s) you are registering for:
Pollywog
Pollywog is a regional network designed to assist families in accessing prenatal, parent/child and parenting classes. We also offer connection to resources including parenting support, primary health care, child care, financial support and early learning opportunities. Open to all and at no cost.
Would you like to join "Pollywog" to learn more about classes and workshops near you?
Clear selection
Payment Information
The cost for Live and Learn with Your Wobbler is $25. The cost for Live and Learn with Your Toddler is $74. PAYMENT IS DUE BY THE FIRST DAY OF CLASS. Please send your check made payable to:

SRF
PO Box 1528
Philomath, OR 97370.

If you have any questions regarding payments, please email Laurie at Lauri.srf@ruralfamilies.org
Student Consumer Information: The College complies with the Student-Right-to-Know Campus Security Act of 1990. The Annual Campus Safety Report is available from the Campus Security Office, (541) 917-4440, and the Dean of Student Services Office, (541) 917-4806. Retention statistics are available through Registration in Takena Hall, (541) 917-4821. These reports and other pertinent information are available at http://www.linnbenton.edu/future-students/stuff-parents-want-to-know/student-right-to-know

LBCC releases “Directory Information” regarding students, including address and telephone listing, enrollment status (full or part time), major field of study, participation in officially recognized activities and sports, weight and height of athletes, dates of attendance, school or division of enrollment, degrees and awards received. If you do not want directory information released, please complete a Directory Deletion Form in the Registration Office in Takena Hall or Online at http://www.linnbenton.edu/admissions

The policy of Linn-Benton Community College prohibits unlawful discrimination based on race, color, religion, ethnicity, use of native language, national origin, sex, sexual orientation, marital status, disability, veteran status, age, or any other status protected under applicable federal, state, orlocal laws. Students having questions about equal opportunity and nondiscrimination, contact the Dean of Student Services, (541) 917-4848.
Submit
Never submit passwords through Google Forms.
This form was created inside of Linn-Benton Community College. Report Abuse
Google Forms