Conversations That Matter

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The jefferson Clemente

Course in the Humanities
Application for 2018 Clemente Course: “Conversations That Matter”
March 19 - May 30, 2018

Mon/Wed, 6-8:30 PM

Pope Marine Building, Port Townsend WA

to apply: 1) Email:, or call/text Arendt Speser (360-774-6635)
2) fill out this application completely and bring it with you to the interview

Name ______________________________

Address ______________________________________ City _______________State ______ Zip ___________
Home phone ____________________ Other phone___________________
Marital status: ___Single ___ Married ___Separated ___Divorced ___Widowed

Do you have children? ______ If so, how many? ______ Age(s) _____ _____ _____ _____ _____

Would you need childcare to attend classes? _______ Would you need help with transportation? _________
If yes, what kind of help? Bus fare?____ Carpool? ______ Other?____
What is your primary language? English?______ Other? _______________
Ethnicity (Optional): ___White ___ African American ___Latino ___ American Indian ___Asian ___Other

If Other, please identify ___________________________________________

Education: Highest grade completed_______ Are you currently in school?______
If so, which school? ____________________________ If not, are you a HS graduate? ____________
G.E.D. recipient? __________ Working on your G.E.D.?_________
Have you ever attended college?____ If so, when? For how long? ____Which college? _____________
Why did you stop? ________________________________________________________________
Employment/training: Skill/Occupation ____________________________________________

___ Employed full-time ___ Employed part-time ___Unemployed ___Volunteer ___ Interning

Entitlements (such as TANF, SSI, etc) ________________________

Enrolled in other programs (school, recovery, etc.): Yes____ No _____

Names of Programs (Optional)_______________

U.S. Citizen?______ Permanent resident?_______ If not, where were you born?________________

On A separate sheet of paper, please write About yourself, your interests, and why you want to attend THE CLEMENTE COURSE.
Thank you. We look forward to hearing from you soon!

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