Form C

  WINNISQUAM REGIONAL SCHOOL DISTRICT - SAU #59     (Staff Member Copy)

CERTIFICATION OF PARTICIPATION IN STAFF DEVELOPMENT ACTIVITY

Area of Endorsement: ___________________________    ___Goal I   ___ Goal II   ___ Dist Bldg Initiative

  I participated in the ____________________held at ____________________________ on ____________________. Whereas this activity provided professional development in the areas of concern specified in my individualized Staff Development Plan (see FORM A), I am requesting that _____________clock-hours be recorded in my staff development file.

  This form is being used in place of FORM B.  Signatures of staff member and principal/supervisor certify to actual clock-hours of participation.

___________________________________________   ____________________________________________

Staff member                                                                                      Signature of Supervisor

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                                  WINNISQUAM REGIONAL SCHOOL DISTRICT - SAU #59 (Superintendent's Copy)

CERTIFICATION OF PARTICIPATION IN STAFF DEVELOPMENT ACTIVITY

 Area of Endorsement: ___________________________    ___ Goal I        ___ Goal II        ___    Dist Bldg Initiative

I participated in the ____________________held at ____________________________ on ____________________. Whereas this activity provided professional development in the areas of concern specified in my individualized Staff Development Plan (see FORM A), I am requesting that _____________clock-hours be recorded in my staff development file.

  This form is being used in place of FORM B.  Signatures of staff member and principal/supervisor certify to actual clock-hours of participation.

  ___________________________________________     ____________________________________________

                        Staff Member                                                           Signature of Supervisor                                                      

  ---------------------------------------------------------------------------------------------------------------------------------------

                                    WINNISQUAM REGIONAL SCHOOL DISTRICT - SAU #59    (Principal's Copy)

CERTIFICATION OF PARTICIPATION IN STAFF DEVELOPMENT ACTIVITY

Area of Endorsement: ___________________________    ___ Goal I        ___ Goal II        ___    Dist Bldg Initiative

I participated in the ____________________held at ____________________________ on ____________________. Whereas this activity provided professional development in the areas of concern specified in my individualized Staff Development Plan (see FORM A), I am requesting that _____________clock-hours be recorded in my staff development file.

  This form is being used in place of FORM B.  Signatures of staff member and principal/supervisor certify to actual clock-hours of participation.

___________________________________________     ____________________________________________

                        Staff Member                                                          Signature of Supervisor