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CSUN 400

CHIME Institute Observation Request

Please complete the form below. Required fields marked with an asterisk *

First Name

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Last Name

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Home Phone

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Daytime Phone

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Cell Phone

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Email*

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Street Address

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City

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State

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Zip Code

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Total Hours Needed*

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Class for which you are doing your observation

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Instructor's Name

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Number of visits requested, and number of hours per visit

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Specify days & times available

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Other considerations

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What is the purpose of your observation?

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