Professional Learning User Fee

Name: *

Professional Title(s): Dance Teaching Artist Classroom Teacher Non-teaching Artist Administrator Student Other

Address:

City: *

State: * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Foreign

Zip: *

Home Phone:

Mobile Phone:

Email: *

How did you hear about us?: Luna Website Friend Flyer Postcard send to you Email sent to you Child's school Community Calendar Display Ad Other

Demographic info for grant purposes: What are your teaching settings?: studio public school private school charter school university/college community center ECE setting other N/A

Demographic info for grant purposes: If you teach in a public school, what district is it in?: *

Demographic info for grant purposes: What age(s) are your students?: 0-2 3-5 5-6 kindergarten 7-10 11-13 14-18 college/university adults seniors N/A

Demographic info for grant purposes: How many children do you anticipate teaching this academic year?: *

Demographic info for grant purposes: How many of these children have special needs?: *