| Please print all info | |
Name (Given & name you like to be called) | |
| Home Address City State Zip | |
| Home Phone/Cell | |
| Email home /school | |
| Area(s) of Certification | |
| School Name | |
| Address City State Zip | |
| Principal | |
| School Phone | |
| School District | |
| Grade level /classes | |
| Years of Teaching |
Housing requests: Please note roommate preference:______________________________________________
Housing not needed :______( there may be evening events pending schedule)Medical Considerations:
Please share here or with Kathe Stanley any physical limitations or conditions that might impact you during your stay at CLIA.
If you will need a single room (sharing bath) please note. _____________________________________________________________________________________________________
Contact Information: In case of an emergency CLIA staff may contact:
Emergency Contact Person: ___________________________________________________________________
Relation to you:_____________________________________________________________________________
Phone numbers, including area code and extension/cell number: _____________________________________
Permission: In the event of an emergency (illness or accident) at CLIA and the above emergency contact person cannot be reached, I give CLIA staff permission to seek emergency medical care on my behalf.
Signature_________________________________________________________Date: ____________________