.1. Name 

 2. School

3. School City

 4. School Phone:            

5.  Home Phone

6.  Cell  Phone

10. E-mail address  - School

11.E-mail address  - home 

Please Verify: All must be answered YES. 

12. Please indicate YESI am willing to collaborate, share with others as needed for designing and/or teaching an online course.

13.Please indicate YES  I accept the Mission and Purpose of Mercy Learning Online.

14. My teaching credentials are current and on file at the school named on this form.  Please indicate YES

15.. All information on this form is accurate and current. Please indicate YES

16. How many summers have you taught with Mercy Learning Online. (not including 2010)

17. The course(s) I will be teaching for Summer 2010 are:

17..Submitted by   18. Date