The Foundations of Practice Level 3 Training, "Community Sustainability," is an eight module distance education course. I understand that I am enrolling in the entire eight week course PLUS the online course site. I will receive a certificate of completion if I participate in at least seven of the eight teaching modules. The sessions will be held on the following Wednesdays: January 19 and 26; February 2, 9, 16 and 23; March 2 and 16. All sessions will run from 3:00 p.m. - 4:30 p.m. (eastern time). All connection information will be emailed to you on January 14, 2011.

First Name

Last Name

Preferred Name

Title

Organization

Street Address

City

State

Zip Code

Phone/Fax

E-mail

County, Area or State Appointment: County Area State

Primary area of responsibility: 4-H CRD FCS ANR Other

Years of experience in this field:

Percent of time spent in community development work:

Please Note: Information on this form may be shared with other participants.
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If you are paying by check DO NOT HIT THE SUBMIT BUTTON, please make check payable to Penn State University and mail with a copy of this form to: NERCRD, 7 Armsby Bldg., Penn State University, University Park, PA 16802.

Note If You Are Paying by Credit Card: After submitting your completed registration, you will be automatically directed to NERCRD's secure on-line payment application.

To keep a copy for your records, please print the form before submitting.