Thank you for your interest in the Pulse of Southern Maryland telephone opinion surveys. Please complete this form to register for a session. All sessions begin at 6:00pm and last until 9:00pm. Students will be expected to participate for the entire time. Free pizza will be provided.

**Please note: YOU ARE NOT REGISTERED until you receive an email with "Pulse CF" in the subject. Confirmations are created manually, so you will not receive an instant reply. If you have questions, please contact Pat Schroeder at patsc@csmd.edu.

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* 1. What is your last name?

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* 2. What is your first name?

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* 3. What is your birth date? (mm/dd/yyyy)

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* 4. What is your email address? Please note: YOU ARE NOT REGISTERED until you receive an email with "Pulse CF" in the subject.

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* 5. What is your phone number?

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* 6. Which Pulse sessions would you like to attend? Please select each session you wish to join.

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* 7. Class Information:
If you are earning extra credit, please enter your class (Example: BAD 2600-70626)

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* 8. What is your instructor's last name?

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* 9. If you will receive credit from another instructor, enter that instructor's last name here:

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