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Civic Life Online Seminars Enrollment Form

Fall 2017/Winter 2018

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. Your preferred email address?

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* 4. Your preferred phone number?

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* 5. Type of phone

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* 6. Name of your school

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* 7. City

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* 8. State

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* 9. Zip Code

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* 10. Please select the series you would like to attend

2017 - Tuesdays at 5:00 PM - Oct 17, Oct 24, Oct 31, Nov 7, Nov 14, Nov 21, Nov 28, Dec 5

2017 - Wednesdays at 6:00 PM - Oct 18, Oct 25, Nov 1, Nov 8, Nov 15, Nov 22, Nov 29, Dec 6

2018 - Tuesdays at 5:00 PM - Jan 9, Jan 16, Jan 23, Jan 30, Feb 6, Feb 13, Feb 20, Feb 27

2018 - Mondays at 5:00 PM - Jan 8, Jan 22, Jan 29, Feb 5, Feb 12, Feb 26, Mar 5, Mar 12

Comments

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* 11. Tell us in a few sentences how you hope to benefit from the Civic Life training/coaching?

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* 12. Tell us in a few sentences about your school

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* 13. Do you have experience with digital media? Please describe

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* 14. Please share any additional comments and/or questions

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* 15. Will the program be implemented in your classroom this semester?

Yes

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* 16. If yes, how many students do you expect will participate?

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 17. Please tell us where we should send the invoice ($775 per teacher)

First Name, Last Name

Company/School

Street Address

City

State

Zip

Email address if you want to receive invoice electronically