Request for CLS Waiting List Application

First Name:*
Last Name:*
Address:*
City, State:*
Zip:*
Email Address:
Day Phone:*
Evening Phone:*
Where you heard about our program:
Education:
Hobbies & Interests:
Would you be willing to teach a course of interest? If so, please list potential topics:
Check if applicable:
Former Member
Spouse of Member
Presenter (see CLS web-site for details)