Address _________________________________________________________________

City _______________________________ State _______________ Zip _____________

Telephone _________________  SS# ______________________

Email ____________________________________________

Assignment (Building/School/Grade) _______________________________________

Position (Teacher, Adm., Counselor, Media Specialist, etc.) ___________________

PLEASE REGISTER FOR A COURSE AS SOON AS POSSIBLE TO AVOID CANCELLATION OF CLASS.  Courses must be appropriate for the participant and all requirements must be completed and verified before credit can be awarded.  You will be notified if a class is full or has been canceled; otherwise, you will be expected to attend.

TUITION:  Tuition fees of $10.00 per SDU are due prior to the class.

Course Title____________________________________________  Course #___________

Date(s)_______________________________ Location_________________________________

Course Credit __________________ PLU’s  ____ Tuition $__________($10.00* per PLU)

Supervisor's Signature_________________________________________________

Print out this form and fax or send to Staff Development Department, Bradley Library,
Fax 748-2091.