First Name      Last Name

Birth Date (mm/dd/yyyy)                    Male Female

Address

City      State      Zip

Phone           E-Mail Address

Dates Requested in attending CueSport College       - to - (mm/dd/yyyy)

Formal Education:

Military/Peace Corp History:

Hobbies:

What I Enjoy Teaching (fundamentals, mental, somatics, Inspirit, etc...):

Who I Enjoy Teaching (youth, elderly, handicap, etc...):

How I Enjoy Teaching (individual, groups, etc...):

Where do I primarily teach:

Approximate accumulated teaching hours:

List student references with phone numbers:

Why I Enjoy Teaching:

Expertise of the Cueing Arts or other Sports: (list degree, certification, self-study, and teaching/instruction history):

Instructor Training and/or Recommendations:

'A confirmation paid deposit is required to reserve all tentative enrollment and/or dates'

*** For your convenience we accept all major credit cards ***

* Please expect our follow up telephone call to receive your deposit for confirmation of enrollment *

CueSport College International

325 S. Bellevue Ave.

Peoria, IL 61604

(309) 697-2774