PEP Outreach Courses

Date: 07/03/2009

Affiliation/Organization/Institution & Department (Please use proper case, this will appear on your name tag!):

First Name (Please use proper case, this will appear on your name tag!):

Last Name (Please use proper case, this will appear on your name tag!):

Daytime Phone:

Email (COMPLETE Internet Email Address!! jdoe@someplace.com):

Verify Email:

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Mailing Address (Must match your billing address on your credit card statement):
Street Address:
Address cont.:
Address cont.:
City:
State: Postal/Zip Code:
Country:

Contact Address (If YOUR contact address does not match the above, or you can not receive mail at the above address, please provide your address here):

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Background Information
Highest Degree:

Institution:

Graduation Date:

Current Information
Current Position:

Type of Institution:
Private 2 Year High School
Public 4 Year
Previous Chautauqua Experience (Course, Center & Year):

Special services or disability related accommodations needed:

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PEP Outreach Courses
Course descriptions can be found at http://www.stonybrook.edu/ceie/chautauqua/descriptions.shtml

NOTE: Please make sure you view the course descriptions as the location of these classes vary and may require travel arrangements.

Application fee: There is an application fee of $50 per registration (not per course). The application fee is not refundable unless the course is canceled then the application fee is automatically refunded.

Courses:
Please select the course(s) you wish to register for.

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SECCT System developed by Last Modified 07/03/2009 08:16:31 PM