Contact Information:
First Name:
Last Name:
Mailing Address:
City:
State:
Choose one
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Contact Phone Number:
Email:
Professional Website: (optional)
Class Information:
CLASS TITLE or SUBJECT:
PREFERED CLASS LENGTH (check all that apply):
5 days
2 days
1 day
1/2 day
PREFERED SEASON (check all that apply):
Winter
Spring
Summer
Fall
Anytime
BRIEF DESCRIPTION OF PROPOSED CLASS:
OR attach class description as a separate document:
Prospective Students:
TO WHOM MIGHT THIS CLASS APPEAL?
IDENTIFY PLACES TO RECRUIT STUDENTS:
HOW WOULD YOU HELP US RECRUIT STUDENTS?
Materials & Equipment Needed:
INSTRUCTOR WILL PRVOVIDE:
STUDENT WILL PROVIDE:
THE CLEARING WILL PROVIDE:
PROPOSED FIELD TRIPS OR SPECIAL ACTIVITIES:
Instructor Information:
HAVE YOU TAUGHT AT THE CLEARING BEFORE?
No
Yes
WHICH CLASS(ES) DID YOU TEACH?
OTHER RELEVANT TEACHING EXPERIENCE:
EDUCATIONAL BACKGROUND:
REASONS FOR WANTING TO TEACH AT THE CLEARING:
COMMENTS: