Fall 20_______

                                                                                                         Winter 20_______

Name:                                                                                                                

Address:                                                                                Phone: (W)                           

City, Zip:                                                                               Phone: (H)                             

NAME OF CLASS:                                                                                                           

Location of class:  Building:                                                Rm No.                                 

Off Campus Location:                                                                                                      

Instructor:                                                                 Day:                            Time:                 

DATE CLASS BEGINS:                   DATE CLASS ENDS:                        No. of wks:             

                                                                                                    Cost:                    

                                                                 Additional Materials Cost:                         

                                                                                       Amount Paid:                           

            Return with payment to: Western Adult and Community Education

                                                                                     3950 Catherine Street

                                                                                     Jackson MI  49203

                                                                                     (517) 841-8700                     

Please list any enrichment classes you would like offered:

Would you be interested in teaching an enrichment class?             Yes    No