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Pre-registration
Completing this form does not guarantee you a place in the class. The purpose of this pre-registration form is to gather information regarding the extent of interest in this course offering.
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For the Love of Learning: Individuals and Societies in a World Loose With Uncertainty
Space is limited to 16 participants with a minimum of 12 needed to offer the course.
First Name
*
Your answer
Middle Name
Your answer
Last Name
*
Your answer
Address
*
Your answer
US Citizen
*
Yes
No
School (used to balance elementary and secondary)
*
Your answer
E-mail
*
Your answer
Home Phone
Your answer
Cell Phone
Your answer
**Please remember that completing this form does not guarantee you a place in the class. This is the first step! Professor Miller-Lane will be in touch with you very soon.**
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