CalChautauqua

2012 Course Schedule

Chautauqua Short Courses Form

NOTE to non-professinal educators: This form was designed for professional educators. Put your home address in the Office area(question 8-13). If there are required questions that do not apply to you, simply put N/A) .

Application
1.Course:
2.Title:
3.First Name:
4.Middle Name:
5.Last Name:
6.Department:
7.Institution:
Office Address
8.Street:
9.City:
10.State
11.Zip Code
12.Phone:
13.E-Mail:
Home Address
14,Street:
15.City:
16,State
17.Zip Code
18.Phone:
19.Preferred Mailing Address:
Demographic Background
20.Gender:
21.Highest Degree:
Current Position
22.Type of Institution - Public or Private:
23.Type of Institution - 2 or 4 year, Secondary:
24.Your Primary Responsibility:
Other:
Teaching Background - Number of Years Taught
25.College/University:
26.Secondary:
27.Other:
28,Specify:
29.Courses Taught:
 
30.Previous Chautauqua Experience
(if any):

31.Statement of Interest:

In the following space indicate why you want to take this course. How will you use it?
32.How did you learn about this year's program?
Other:
33.Do you need any special services or disability accommodations? Please also indicate the preferred way you want to be addressed (e.g. Robert or Bob)