SEP Enrollment Form

Please print this page, complete, and return via campus mail to Roxanne Burnett in the Center for Teaching, Learning & Leadership.  Note:  Staff will have three years from the semester of enrollment to complete the requirements for the SEP program.  

Date (mm/dd/yyyy):  _____________________________

Name: ___________________________________________

Title: ____________________________________________

Full-time___________                   Part-Time___________   

Department: ______________________________    Campus: _____________________

Email: _____________________     Phone/Ext.: __________________

 Supervisor:  ___________________________  Phone/Ext:  __________________

Have you ever taken a class or course exclusively online? ________ yes _________ no

Would you be interested in any workshops online?   __________yes   ___________no