Class Name*
         

Class Number*
         

Ship Quantity*
         

Person submitting form:

Class membership:

Women's Class     Men's Class     Mixed (Men & Women)     Couples Class      

Does your class use videotaped lectures?

Yes     No

Section 2 - Class Meeting

Church or other location of class meeting
         

Address
       

City, State, Zip
       

Phone

Class Meets on (day)
       

Time (from)     (to)      a.m.     p.m.

Class schedule cycle (example: August to April)
       

Section 3 - Leadership Meeting

Location of Leaders Meeting
       

Leaders Meeting Address
         

City, State, Zip
       

Phone number
       

Leadership meets on (day)
       

Time (from)     (to)      a.m.     p.m.

Section 4 - Children & Youth Program

Does your class have a children's or youth program? (If No, skip to Teacher Information section and go to Section 5.)

Yes     No 

Does your class make accommodations for Crib/Toddler age children?

Yes     No

If yes, approximate number of children in this area

If yes, does your class collect funds to pay for attendant and if so, how?

Does your class have a pre-school program (ages 2 - 5 years old?)

Yes     No

If yes, please provide the following:

Approximate number of children and teachers involved in this area

Does your program have a program for elementary and or Jr. & Sr. High students?

Yes     No

If yes, please provide the following:

Approximate number of children and teachers involved in this area

If there is additional information about how your children's/youth program functions in your particular class that would be helpful to us in supporting your class, please share briefly:

Section 5 - Leadership Information

Teacher information

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

How long in this position? 

If married, Spouse's Name 

Has attended a Leadership Training Conference  Yes     No

If so, date of last conference attended  -- mm/dd/yy

Assistant Teacher

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

How long in this position? 

If married, Spouse's Name 

Has attended a Leadership Training Conference  Yes     No

If so, date of last conference attended  -- mm/dd/yy

Administrator

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

How long in this position 

If married, Spouse's name 

Has attended a Leadership Training Conference  Yes     No

If so, last conference attended  -- mm/dd/yy

Materials are shipped to:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

How long in this position 

If married, Spouse's name 

Has attended a Leadership Training Conference  Yes     No

If so, date of last conference attended  -- mm/dd/yy

Children/Youth Coordinator

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

How long in this position 

If married, Spouse's name 

Has attended a Leadership Training Conference  Yes     No

If so, date of last conference attended  -- mm/dd/yy

Class contact, other than above

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

How long in this position 

If married, Spouse's name 

Has attended a Leadership Training Conference  Yes     No

If so, date of last conference attended  -- mm/dd/yy