Laker Mascot Application Form
Name
First Name
Last Name
Student ID
6-Digit Student ID
Address During School Year
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Cell Phone Carrier
Provide Cell Phone Carrier
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What year are you?
Freshman
Sophomore
What clubs, sports or activities are you involved in at ILCC?
If you work off campus, what is your typical schedule?
Do you have a car on campus?
Yes
No
Have you had a sports physical or medical physical in the past year?
Yes
No
Can you provide proof of current health insurance coverage?
Yes
No
Submit
Should be Empty: