La' James International College Distance Education

Application For Enrollment

Select the distance learning program in which you are submitting enrollment *
CONFIDENTIAL
Name First Last
Social Security #
Current Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone - (###) - ### ####
Cell Phone - (###) - ### ####
Birth Date / MM / DD YYYY
Email
Name and Address of person to be notified in the event of an emergency:
Name First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Relationship:
Phone - (###) - ### ####
Parent or Guardian's Name and Address:
Name First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
Education:
Program Scheduled Class Start Date / MM / DD YYYY
High School Attended
Year Graduated Or GED Completion Date
College or Vocational School Attended
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Years Attended
From (month & year):
To (month & year):
If you attended a college or vocational school, did you receive financial aid while attending? Yes No
If checked yes, what is your DRN (Data Release Number)?