Application

Please copy and paste the following to an email or word document and either email it to biesingerm@gmail.com or mail it to 1113 S. Main St., Medina NY, 14103

Name:____________________________________________________________

Address:__________________________________________________________

Home phone number: _________________     Cell phone number: _____________________
Email:________________________________    Gender:___  Age: _____

Talents:________________________________________________________________________________________________________________________________________________________________

Educational strengths or areas of interest:________________________________________________ ______________________________________________________________________________________________________________________________________________________________________

Interests/Hobbies:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Reason(s) you would want to attend: ___________________________________________________ ______________________________________________________________________________________________________________________________________________________________________

Would you be willing to present?  If so, what topics could you present?  
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Would you be willing to teach a class or lead an activity?  If so, what type of classes or activities would you like to conduct?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What local areas of interest would you like to have us consider in using in our itinerary and why?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

In the following space or in an attached page, would you please share an experience where you learned something in a meaningful way.  Please share any details you feel comfortable sharing.