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