Professional Learning Certification Form
Each participant who would like to request contact hours credit for HGRESA sponsored events must complete a certification form. Upon receipt of fully completed form, a certificate will be issued to the requesting individual.
Full Name:
District (if applicable):
School (if applicable):
Email Address:
Direct Contact Phone Number:
What is the name of the event, meeting, event, etc. for which you are requesting contact hours? (Please include the number of the course with the title.)
What was the date of the event (if a live or face to face event)?
MM
/
DD
/
YYYY
By submitting this form, I certify that I have completed the following required tasks, uploaded required evidence documents, and submitted the form to earn contact hours:
It is my understanding that I will receive 2 hours beyond the scheduled time for the class to reflect on the information, to plan and then present the information to an educator or to educators during a PLC time. I will upload verification of the event which can include sign-in sheet or verification from an educator. Considering this information, how many contact hours are you requesting?
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