Target Learning
REQUEST FOR A PERSONAL LEARNING PROGRAM

Name                      

E-Mail Address     

Telephone                  Ext.     Fax 

Street Address     

City                            State     Zip  

Select a Program -----Customized Program----- OR --Target Reading --Target Writing --Target Memory --Target Thinking --Target Listening --Target Management --Target Study Skills
 

1.  If you chose "Custom Program", select the topics you want included:

Study Skills
Listening Skills
Memory Improvement
Business Writing
Business Grammar
Speed Reading
Critical Thinking
Creative Thinking
Strategic Reading
Management Skills
Public Speaking
Team Building
 

2.  List any specific learning objectives you would like to accomplish.

3.  What problems/issues (at work, school, or home) do you face that may require improved learning skills?

4.  Please list any special learning requirements, needs or considerations.

5.  If currently employed, what field do you currently work in?

Administration
Information Technology
Engineering
Accounting
Legal
Marketing/Sales
Customer Service
Operations
Manufacturing
Shipping/Receiving
Security
Construction
Other

6.  If currently in school, what grade are you in? (check all applicable boxes)

9th Grade
10th Grade
11th Grade
12th Grade
College Freshman
College Junior
College Sophomore
College Senior
College - Graduate Level

7.  If not currently in school, what grade level have you completed? (check all applicable boxes)

9th Grade
10th Grade
11th Grade
12th Grade
College Freshman
College Junior
College Sophomore
College Senior
College - Graduate Level
College - Post Graduate Level

8.  When would you like to begin your Personal Learning Program?

Unknown at this time
September 2010
October 2010
November 2010
December 2010
January 2011
February 2011
March 2011
April 2011
May 2011
June 2011
July 2011
August 2011