On-site Form Module Test

On-site Request Form

To be Completed by the District

Intended Audience

 General Education Teachers Special Education Teachers Administrators
 Paraprofessionals Parents Specialists

Training Requested

Name of Training:
Training Date(s) Requested:
Start Time(s) Requested:  End Time(s) Requested:
Approximate Number of Participants/Attendees:
Level of Training/Knowledge in Subject Matter:  Introductory  Intermediate  Advance

Location of Training Facility

LEA Office/Classroom:  

Local Education Agency (LEA):

Available Training Facility Equipment (Please indicate training equipment our training staff will have access to.)

 WiFi / Internet  Multi-Media Projector  Handheld Mic  Lapel Mic  Extension Cord  None

Technology Contact Person (Please indicate contact information for technology on-site or tech staff.):

Individual Requesting Training (Requestor's Name):

Contact Phone for Requesting Individual:

Email Address for Requesting Individual:

Training Day(s) On-site Contact Person:

Contact Phone for On-site Contact Person:

 

What are the expected outcomes you hope to achieve as a result of this training? (Outcomes for Staff)
BY CHECKING THIS BOX, I AGREE AND CONFIRM THAT THE SIGNATURE I HAVE TYPED BELOW IS THE ELECTRONIC REPRESENTATION OF MY ORIGINAL, HANDWRITTEN SIGNATURE WHEN USED ON THIS DOCUMENT. I FURTHER UNDERSTAND THAT SIGNING THIS DOCUMENT USING MY ELECTRONIC SIGNATURE SHALL HAVE THE SAME LEGAL FORCE AND EFFECT AS THE ORIGINAL.
 I AGREE
Email address you would like the confirmation sent to:
Special Education Director / Site Administrator's Initials (Administrator's initials are a substitute for signature on this digital form)
Today's Date: 

 

For CAHELP Completion

Date On-siteTraining Approved:  Materials to be prepared by:  SELPA  DISTRICT
Date E-mail Notification sent to Director/Requestor:  Assigned Access Training ID No.: 
Traininer/Presenter: 
Approving Program Manager's Initials:  Completed  Denied  Pending
Notes: 

 



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