Name _____________________________

Phone _____________  Cell _______________

Email _____________________________

Address __________________________________________                            

City____________________________ State _______ Zip ___________

Course Title ____________________________________________________________

Course Description   ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Total Honorarium Requested for Course (not per student or per session) $_____________

Min # of Students ______          Max # of Students_______

Experience and/or Related References ________________________________________________________________________________________________________________________

Number of Sessions _______   Night of Week______________________

Start Time *_________             Length of Class____________

Please Check if Students must furnish supplies______

List of Supplies ___________________________________________________________

If supplies will be provided, please indicate the cost per student $_______                           (This cost will be paid directly to you on the first night of class)

Space Requirement ___________________________________________________________

* Evening Classes – start time may vary from 6 – 7:30 p.m.

Mail to Community Classroom c/o Dori Waters
1658 Falls Road
Clarks Summit, PA 18411 or email or to gatheringplaceCS@gmail.com