First Name Last Name

School

Position

Please Choose One: Workshop/Conference Graduate Level Course

Workshop/Conference/Course Dates:

Number of Graduate Credits (please type 0 if not for credit):

Name of Professional Development Activity:

Sponsor (UVM, ASCD, etc.):

Make check payable to (type "free" if no charge):

Send the check and/or registration materials to the following address:

Address 1:
Address 2 :
Town:
State:
Zip:

Cost (type "0" if no charge): $

Did you pre-register for this course? Yes No
(If not, we will register you with payment.)

Choose one: Advance Payment to Vendor Reimburse Teacher/Administrator

(Note: This form must be approved before starting the workshop/conference/graduate level course. Pre-paid forms must be submitted at least 30 days before date of activity.)

How will this activity support school and action plan, school and/or supervisory union goals and your IPDP?

Please Note Upon completion of this activity you will be required to write about what you learned, how you have shared the information, and how you will apply your new learning to your current assignment.

---

Before printing this form click on the "Check Form for Errors" button below. When the form is free of errors click the "Print Form" button below. After printing, sign the form below and submit the form to your principal or supervisor.

Please be sure to print the form on the correct color paper. SATEC should use blue paper, SACS should use yellow paper, Fairfield should use pink paper, and FCSU Central Office staff should use green paper.

YOU ARE REQUIRED TO ATTACH A COMPLETED REGISTRATION FORM, MATERIALS AND DESCRIPTION OF THE ACTIVITY OR COURSE IN ORDER FOR THIS REQUEST TO BE PROCESSED.

	Do this first!		Then do this	Print Form

Requestor Signature: ____________________________ Date: ________________

*PRE-PAYMENT AUTHORIZATION: In accordance with the provisions of the master contract, I hereby agree to repay in total the prepayment costs and, where appropriate, authorize the School District to make payroll deductions to recoup said costs in the event that I am unable to meet the prescribed terms and conditions described herein.

---