DMJ 2017/2018 PD Request Form
This form is to be used to request PD for June 1, 2017 - May 31, 2018
Email address *
Employee Name *
Your answer
email address *
Your answer
Please choose your school. *
Date(s) of professional development *
Your answer
Time of meeting
Your answer
Professional development location *
Your answer
Name of PD activity *
Your answer
Presenters Name
Your answer
Number of hours *
*PD full day = 6 hours
Your answer
Is this a state required PD session? *
ie - Tier 1 training, Teen Suicide, Advanced Placement
Required
How does this PD activity address student achievement and the needs of the school improvement plan AND your PGP? *
All PD must correlate to student achievement/school improvement plan
Your answer
How will the cost of this PD activity be covered? *
Required
If other please explain
Your answer
Registration Fees *
Your answer
Lodging Expense *
Your answer
Travel/Mileage Expense *
.35 X miles round trip = $mileage reimbursement
Your answer
Meal Expense *
meals are only reimbursed if overnight stay is involved.
Your answer
Total PD activity expense *
Enter the total expense of the workshop by including all expenses listed above.
Your answer
I understand if I register for a workshop and do not attend or leave the district I am responsible for reimbursing the school for the expense of the workshop. *
Required
Restrictions are placed upon the use of Federal funds for the state required 36 PD hours. I understand that if Federal funds are used to pay for the PD then those hours earned cannot count towards my state required PD hours. *
Required
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