SSN or W#: 
Name:   
E-mail: 

Postal Address:
Street (line1): 
Street (line2):           
City:          
State:        ZIP Code:   


Home Phone:     
Work Phone: 
Cell Phone:

Course I want to teach in the:
Spring Summer Fall 20
Course: 

Program Objective:
           
Time:           
Day(s):   
Length of class:    
         
Cost: 

What is your target audience? 

What is the minimum and maximum number of participants? 

Evaluation Procedure (Discussion, Lecture, Critiques)

Are additional materials required?(Give cost)

Will you advertise for the course? Yes:           No: 

Are there medical or legal requirements for the class? Yes:         No: 

Questions/Comments

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