Student Name: ___________________________________ Date: ______________
Address: ____________________________________________________________________________
____________________________________________________________________________
Telephone: ( )
-_________ - _________
Graduation Year: _______________________________
FOR A CREATIVE EXPERIENCE ANSWER THE FOLLOWING QUESTIONS:
1. When will the activity begin? ________ end?_______
Approximate number of hours
per week? __________ total hours? ______
2. Describe your proposed activity:
3. State clearly those skills, proficiencies, measurements, and/or state
of mind you plan to achieve through your proposed activity:
4. Explain how you plan to supervise, measure, or evaluate your proposed
activity:
5. Who will attest to your participation in this proposed activity?
(State name, business, address, and telephone number):