Students's First Name

Student's Last Name

Student's Birthdate

Parent or Guardian Information
(if student is under 18 years)

E-mail

Street Address

City / State / ZIP

Phone

Field Courses Interested In
(Title, Dates, Location, Session)

Comments / Questions

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Or go ahead and contact:

Mersiha Alic
Director of Community Education Programs
9910 Dupont Circle Drive East
Fort Wayne, IN 46825
Phone: 260.483.4949
E–mail: alicm@trine.edu