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2. Personal Information
4. First Name
5. Last Name
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Phone Number
16. Alternate Phone
18. E-Mail Address
20. What type of instruction do you provide?

    1. Art
    2. Dance
    3. Music
    4. Drama
    5. Voice
    6. Other (specify below)
21. What age groups? (Check all that apply.)

    1. 0-5 Preschool
    2. 6-12 Youth
    3. 13-17 Teen
    4. 18+ Adult
    5. All ages
23. If "Other," please specify
25. Please list your past experience
27. Name of class
28. Host Facility
30. Address
32. City
33. State
34. Zip
36. Program Coordinator
37. Phone Number
39. Name of class
40. Host Facility
42. Address
44. City
45. State
46. Zip
48. Program Coordinator
49. Phone Number
51. Name of Class
52. Host Facility
54. Address
56. City
57. State
58. Zip
60. Program Coordinator
61. Phone Number
63. Additional experience (optional)
65. Syllabus/Summary of Course
    Please attach a syllabus or a summary of the course content for review.
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67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field