Institution: ___________________________________ Teacher: _______________________
City: _________________________ Start Date: _____________ Stop Date: _____________
| NAME (PRINT CLEARLY) | ID NUMBER | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 |
Note: All information must be complete for students to receive credit. Students must attend at least 9 Chapter class sessions of 12/13-week study and 4 of a 6-week study to receive credit. We must have START and STOP dates to complete our Database records.