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* Instructor's Name: * E-mail: * Phone:

* Subject Area:

* Course Title: * Students enrolled:

Course Subject #: Course #:

*Where:

Library:

Classroom:

*Date (1^st Choice): *Start Time: *End Time:

Date (2^nd Choice): Start Time: End Time:

What assignments, skills, topics and/or resources would you like incorporated into the session?

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