PROFESSIONAL DEVELOPMENT ACTIVITY
PROPOSAL
SAU 59 –
Component Area ___Goal
1 (Knowledge of Subject) ___Goal 2
(Form A) ___Goal 2
(District/Building Initiative)
___HQT Professional
Development Plan Strategy
:_____________________________________________________ (Refer to
WRSD Prof. Dev. Plan Section IV, p.
24-30 )
Staff
Member ________________________________
Building : _________________
Certification
Code/Area: __________________________
Date:_____________________
Title of
Activity: _____________________________________________________________
Date and
Time _____________________If professional day needed attach PROF. LEAVE FORM
Description of Activity: (attach brochure or
course/workshop description):
____________________________________________________________________________
____________________________________________________________________________
Staff Signature: ____________________ Principal
Signature_____________ Date :_________
CERTIFICATION OF
COMPLETION OF APPROVED ACTIVITY
Evaluation:
How do you plan to implement specific information or strategies you gained from
this activity?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Total
Hours Completed: ______ Staff Member’s
Signature: ____________________________
Supervisor’s
Signature __________________________________ Date: _________________
REQUEST FOR FUNDING (under course
reimbursement policy)
Amount Requested :__________ (cost of registration)
Please
Check:
____
Workshop up to ($700) ___Graduate
Courses (up to 3 graduate courses)
____Title
1, II, IV (please circle) ___Grant
(specify)__________________
Amount Approved:_________________
___I will
register myself and request reimbursement
(submit: receipt of payment, cert of
attendance or grade and copy of approval)
___ Register with prepayment
IN ORDER TO REQUEST
PREPAYMENT, FORMS MUST BE SUBMITTED TO THE SAU OFFICE 30 DAYS IN ADVANCE OF
PAYMENT DUE WITH COMPLETED REGISTRATION FORM.
ONCE COURSE IS COMPLETED, A CERTIFIED TRANSCRIPT MUST BE SUBMITTED TO
SAU 4 WEEKS AFTER COMPLETION OF COURSE.
FAILURE TO SUBMIT THIS WILL RESULT IN A FULL AMOUNT OF THE PREPAYMENT
BEING REMOVED FROM YOUR NEXT PAYCHECK(S).
SAU Administrator Signature _______________________ Date
_________________
