LIFE Class Proposal Form

Instructor First & Last Name*

Academic Credential Acronym (These are to be used if the class you are teaching is related to your credentials - in a relevant field of expertise.) If this does not apply to you or you wish not to include this information, enter N/A.) *

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Instructor Bio: (Please note this information will be included in the back of the printed LIFE brochure, along with all other course instructor/coordinator bios.)*

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Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

If you ever teach on WIU campus, we need 6 things about your car: Make, Model, Color, Year, State & License Number:

Additional Instructor Bio: (Please note this information will be included in the back of the printed LIFE brochure, along with all other course instructor/coordinator bios.)

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If you ever teach on WIU campus, we need 6 things about your car: Make, Model, Color, Year, State & License Number:

If there are more than 2 instructors, please email Emily Roberts at ES-Roberts@wiu.edu or Sally Adams at SA-Adams@wiu.edu.

Course Title: *

Course Term*

Ex.: Fall or Spring

In what format do you want to teach? *

Course Description (Please provide a 3-4 sentence description about your class. Refer to the attached brochure for examples.) *

Course Date(s) (Provide top 2 days or dates. For Example: a Tuesday morning in April; 3 Thursday nights in October; or September 4 and 11 from 9 - 10 am. ) Course Proposal will not be accepted until two course date preferences are received. *

yesno

If yes, please explain what and the estimated cost.

For example: Food, $10 per person; Booklet, $5 per person; Craft materials, $12 per person

How many sessions do you want your class to be?

How long will each session be?

Time Preference (If none, write no preference.):*

Site Preference (If none, write no preference.):*

YesNo

Maximum Enrollment:*

Be aware that LIFE will no longer be creating waitlists once a course reaches its maximum enrollment. Instead, instructors can consider increasing their course enrollment by just a few, which allows for the cancellations and no shows that often occur

Yes (Recommended)No

Technical assistance. Plan to arrive at least 30 minutes prior to class start time so a member of our WESTEC staff can help set up your presentation. (IF SELECTED, YOUR CLASS WILL BE SCHEDULED AT THE WIU UNIVERSITY UNION. WE ARE NOT ABLE TO GUARANTEE TECHNICAL ASSISTANCE AT OTHER COURSE SITES.)MicrophonePodium

Please submit handouts to be duplicated for registrants at least five days prior to the course start date to the Scheduling & Event Services Office on the 1st floor of the WIU Union next to the Brattain Lounge. They can also be emailed to Emily Roberts (es-roberts@wiu.edu) 5 days before your class.

LIFE Class Proposal Form

Instructor Information:

Additional instructor (If applicable):