SSCR - Instructor Registration Form

Professor Registration Form
*Prof. First Name:
*Prof. Last Name:
*Title:
*Email:
*University/College:
*Dept/School of:
*Address:
*City:
*State:
*Zip:
*Office Phone:
Cell Phone:
Home Phone:
*Best Time to Contact you:
*Can we contact you at home?	yes no
*Password:
*Mother's Maiden Name:
*Course#:
*Course Title:
*Enrollment Term:
*Number of Students enrolled:
	* required

Please tell us more:
How do you plan to use SSCR?
Are willing to dedicate 30 minutes per week of training in your classroom?	yes no
Instructional Seminars are available (approx 4 hours of instruction) with Instructional Materials and Lunch provided
Are you willing to host a seminar?	yes no
Are you interested in a Weekday Seminar or a Weekend Seminar?	Weekdays Weekends Either