First Name: ____________________________________________
Last Name: ____________________________________________
Email address: __________________________________________
Mailing address: (to send course materials)
City: ____________________ State: _____ Zipcode: ___________
Phone: ________________________________________________
School/Organization: _____________________________________
Position: _______________________________________________
Course Materials Fee: ------------------------------------------------------- $120.00
Graduate Credit Fee (optional): -------------------------------------------- $ 30.00
3 semester credits from Weber State University, Ogden, UT.
TOTAL: -------------------------------------------------------------------- ________
Please enclose a check or Purchase Order made out to WestEd in the amount of the above total. Send your fees, with this completed application to:
Libby Rognier
WestEd Eisenhower Regional Consortium
730 Harrison St.
San Francisco, CA 94107
If you are applying for credit, include a signed Credit Application with your course application. Space is limited. You will receive email confirmation of enrollment.