Name (First, Last):

Address:

City, State, Zip:

Home Phone:

Other Phone:

E-mail address:

Yes
No

If yes, where?

Adult Education
Adults with Disabilities
Adult Leisure Programs
Afterschool Programs
Aquatics
Course Evaluation
Course Instruction
Course Planning
Early Childhood
Data Collection
Facility Use
Public Relations
School Age Childcare
Senior Programs
Volunteer Programs
Youth Recreation
Youth Development
Other

Yes
No

Why do you wish to serve on the Advisory Council?

What experiences and/or skills do you have that may be valuable to the council?

List any service organizations or professional associations of which you are a member.

Have you ever participated in a Community Education program? If so, what?