MIP A.1 – LCS Member Portal

MIP A.1 Workshop Initiation Form

To be used to initiate in-service activity with the Association and/or Member School/Center. Submit form to the in-service manager annually for proposed or needed in-service activity.

Name of Initiator of Request*
First Last
Date*
Date Format: MM slash DD slash YYYY
School Name*
School Phone*
Title of Workshop or Activity*
Describe the Content of the Workshop Activity*
Name of Instructor/Presenter*
First Last
Credential of Instructor/Presenter*
Files Upload
Please upload a copy of the course syllabus, notes, certificates, or any other materials that may help us understand the training and the presenter.
Drop files here or

Accepted file types: jpg, gif, png, pdf.
Anticipated Number of Participants*
Location of Workshop or Conference*
Street Address City State / Province / Region ZIP / Postal Code Country
Date Workshop Begins*
Date Format: MM slash DD slash YYYY
Date Workshop ends:*
Date Format: MM slash DD slash YYYY
Total Instructional Hours
Please add the total hours of instruction. Do not include breaks, or meals.
Cost per participant*
Please enter "0" if the workshop is free.
Your Email*
Enter Email Confirm Email
Signature*
Please use your mouse to sign here.
Are you the principal or an administrator of the school?
- Yes
- No
Name of your Principal or Director*
First Last
Email of your Principal or Director*
Phone
This field is for validation purposes and should be left unchanged.