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Online Intent to Enroll

Required items are marked by a red *. You must fill these in before proceeding.


Step 1: Demographic Information
 
 
1. Social Security Number:*
(Do not put any dashes or spaces in between the digits.)

Your SSN is protected under FERPA, Federal Guidelines and will not be released.
 
2. Complete Legal Name:
Last:* First: * Middle:
Former Last Name(s) or Maiden Name(s)
 
3. Birthdate (mm/dd/yyyy):* / /
4. Gender:* Male Female
 
5. Are you Hispanic or Latino? Yes, Hispanic or Latino Not Hispanic or Latino
6. Are you from one or more of the following ethnic groups? (Select all that apply):
Asian
American Indian/Alaskan Native
Black or African American
White
Native Hawaiian or Other Pacific Islander
Choose Not to Respond
7. Please identify your primary racial/ethnic group. (Select One)

Asian
American Indian/Alaskan Native
Black or African American
Hispanic or Latino
White
Native Hawaiian or Other Pacific Islander
Choose Not to Respond

 
8. Contact Information:
Email Address:
 
Home Phone: ( ) -
Cell Phone: ( ) -
 
Have you or are you currently serving in the Armed Forces? Yes No
If yes, which brand of the Armed Forces?
Air Force Army
Coast Guard Marines
Navy National Guard/Reserves

9. Legal Residence:
Address or P.O. Box:*
City:*
State:* Zip Code:* County:*
 
A. Have you resided in the Lake Land College district for at least the immediate past 30 days?* Yes No
B. If you recently moved (less than 30 days) into this community college district to establish permanent residency for reasons other than attending Lake Land College, please specify the reason for the move.
C. Are you currently enrolled as a full-time student at Eastern Illinois University?* Yes No
 

10. Are you a U.S. citizen?* Yes No

If no, type of visa Country of Origin:

 
 
 
Clicking the 'Next' button will NOT submit your information. If you would like to make changes or review your information from previous pages, please click the 'Previous' button. All the information you have entered will be saved. If the 'Submit Intent' button is available, please only click it once to submit your information.

 

 

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Lake Land College
5001 Lake Land Blvd.
Mattoon, IL 61938
(217) 234-5253

 

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