Lebanon Public Schools

Application for CEU Equivalent

Request and Verification Form

(Approval must be obtained from Curriculum Office before attending)

 

NAME: ____________________________ SOCIAL SECURITY NUMBER: _____________________

TITLE OF WORKSHOP/ACTIVITY:____________________________________________________

CONFERENCE SPONSOR:___________________________________________________________­_

DATE(S) HELD:______________________  LOCATION:___________________________________

1.     Description (Objectives) of Activity/Conference:

 

 

 

2.     Need statement:

(Specify the district, building or individual goal addressed and/or how the activity supports your district responsibilities)

 

 

 

3.     How might this impact student learning?

 

 

Upon approval, this form will be returned to you. Please resubmit with the following for credit:

 

4.     Evidence of accomplishment:

(Specify sessions attended or attach schedule/agenda and mark sessions attended. If brochure is available, please attach)

 

 

5.     How might you best share this learning?

 

6.     I have completed the activity as approved.

Teacher Signature______________________________

 

Curriculum Director Recommendations:

Approval Signature:_______________________________________       Date:_______________

CEU Equivalent Awarded:______________  Copy to Teacher:_________ Date:_______________