* 1. Full Name:

* 2. Mailing Address:

* 3. Permanent Address (if different from above):

* 4. Email:

* 5. Title of proposed class:

* 6. Class Description:

* 7. Availability (please number based on 1st, 2nd, 3rd choice for class time slots):

* 8. Are you interested in getting more involved?

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