| GSMD ADULT EDUCATION TR-151 (Please complete all information; incomplete forms may be returned) Print or Type: Course # ______________________Title ________________________Dates(s)______________________ If course cancelled, please note second or third preference: 2) Course#___________date__________________3) Course #_______________date__________________ COURSE FEE (if any): $____________________(check / money order made out to GSMD) Please use the name as shown on your GSUSA membership card, if you have one: GSUSA IDENTIFICATION NUMBER (from your membership card):_______________________________ NAME____________________________________PHONE (day) (________)________________________ ADDRESS___________________________________PHONE (eve) (_______)________________________ CITY____________________________________________ZIP_____________________________________ E-MAIL__________________________________________PAGER(_______)_________________________ CLUSTER____________NSU#______________TROOP#______________AGE LEVEL_________________ Dates of courses completed (refer to your training card): [______] Volunteer Application submitted (new volunteers only) New Volunteer Orientation__________________________________________________ Basic Leadership__________________________________________________________________________ Diversity Awareness (1) ___________________________________________________________________ Outdoor Program Facilitator - Beginning_______________________________________________________ Outdoor Program Facilitator - Advanced_______________________________________________________ To accomodate our diverse membership, please indicate whether you have any special needs that should be addressed to enhance your enjoyment of this course (i.e., handicap accessibility, dietary resstictions, etc...) ________________________________________________________________________________________ ________________________________________________________________________________________ Send this registration to GSMD, Training Registrar, 500 Fisher Bldg, 3011 W. Grand Blvd, Detroit, MI 48202. If you have questions, call the Training Registrar at 313.972.4475, X-282. |
| Office Use Only Date Rec'd________________________________ Fee Amt. Rec'd____________________________ Date Confirmation Sent_____________________ |
| Trainer Use Only (check / initial appropriate line) [ ]Completed course _______________________ [ ]Incomplete_____________________________ [ ] No Show_____________________________ |