Request to Receive Mailings

Would you like to receive more information about one of our programs or be added to our mailing list? If so, please take a few moments to complete the request form below.

First Name:

Last Name:

E-mail Address:

Street Address 1:

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City:

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Please include me in the following program mailing(s):
(Please check all that apply)

Professional Programming:

Teacher Education Programs	Community Health education
Exercise & Sport Science	Human Services
Science and Health

Personal Development:
Youth Programs	Arts and Humanities
Learning in Retirement	Computers and Technology

Services:
Conference Services
Online Course Development	Customized Program Development

About yourself:

We appreciate your request! In order to better serve you, please tell us a little more about yourself.

Age:
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Education:
UW-L Graduate:
What is your experience with Continuing Education and Extension at UW-L?
How did you learn about UW-L Continuing Education & Extension? (check all that apply)
Word of mouth	Search engine
Newspaper or other media story	Billboard
Brochure	Other Web site
E-mail	Other