2026 Student Workshop Registration Form

Student Workshop Registration Form

Complete each section. Most fields are required. All unenrolled applications are automatically deleted after 30 days.
I will be a
STEP 1: Watch the Video

STEP 2: Program Selection
I want to register for
Most classes 90 minutes long. Some classes 1 hour or 2 hours long. When are you able to take classes? Thinking about your transportation, work, and family needs, check all times that work for you.
First Choice
Second Choice
My one-time payment of $10.00 covers 1 workshop enrollment only. All payments are non-refundable.

PERSONAL DATA
How did you hear about us?

Other
Case Details

Complete the following sections completely.
Case Worker's Name

First NameLast Name
Case Worker's Organization
Case Worker's Email
example@example.com
Case Worker's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Surname/Family Name, First Name, Middle Initial
Type it as it appears on your government issued ID
Gender
Your Birthday

MonthDayYear
Remember: The month goes before the day
Your Email Address
example@example.com
Main Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
It is okay to put the same number twice.Format: (000) 000-0000.
Current Home Address
Street name and numbers only
City
State
Zip
Number of people living in your household
Marital Status
Number of children living in your household under 18
Annual Household Income
Emergency Contact's First and Last Name
Emergency Contact's Phone
Format: (000) 000-0000.
Emergency Contact's Relation to You
ETHNICITY
I was born in
My first language is
In my first language, I can
I am
Race
If multi-ethnic/multinational, please share how you identify
Education Level
My education is
Employment Status
MILITARY
Are you a Veteran of the U.S. Military?
Are you currently active in the U.S. Military or Reserve?
Are you currently on Military Probation or Parole?
If "Yes" to above, Probation Officer Name and Phone Number
Format: (000) 000-0000.
PHOTO RELEASE
I hereby grant LCFBC permission to use my likeness in a photo, video or other digital media in any and all of its publications, including web-based productions, without payment, or other consideration. I understand and agree that all photos will become the property of LCFBC and will not be returned. I hereby irrevocably authorize LCFBC to edit, alter, copy, publish or distribute these photos for any lawful purposes. I hereby hold harmless, release and forever discharge LCFBC from all claims, demands and cause of actions which I or my representatives on my behalf may have by reason of this authorization.
Initials
I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION, AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF UNDER 18, I HAVE OBTAINED THE REQUIRED CONSENT OF PARENT(S)/GUARDIAN(S) AS EVIDENCED BY THEIR SIGNATURE(S) BELOW.
Applicant Signature
Today's Date

MonthDayYear
Date
ParentGuardian Signature
Date

MonthDayYear
Date
Name

First NameLast Name
Should be Empty:

Student Workshop Registration Form

STEP 2: Program Selection

PERSONAL DATA

Case Details

ETHNICITY

MILITARY

PHOTO RELEASE