MIP B.1

MIP B.1 Outside Association

Prior approval for outside association or outside school or center workshops. This form is for all personnel (instructional, non-instructional, and administrative).

Name*
First Middle Last
Your Email*
Enter Email Confirm Email
School Name*
Phone*
Expiration Date
MM slash DD slash YYYY

Please enter the expiration date of your current ILCS or state professional certificate, if applicable.
Point Assignment*

Please indicate the area of certification for which you want your inservice points to be counted.
Workshop or Conference Title*
How is course delivered?*
- Face-to-face classroom
- Online
- Hybrid (some classroom/some face-to-face
Location of Workshop or Conference*
City State / Province / Region ZIP / Postal Code Country
Website for workshop or conference*
Date Workshop Begins*
MM slash DD slash YYYY

Please enter the date the workshop begins, or the date that you will begin the course (if online).
Date workshop ends:*
MM slash DD slash YYYY
Time Workshop Begins*

: Hours

Minutes
Time workshop ends*

: Hours

Minutes
Evidence of Need*
- Perceived need of staff
- School-focused plan
- Content data knowlade
- Association determined priority
- Accreditation determined priority
- Re-certification Requirement
Note: If the provider is not on the Approved Provider List, you must attach copy of the program which you are attending. This must show proposed activities and times in hours. One (1) full day must be six (6) hours. One half-day must be three (3) hours. One (1) hour equals one (1) point. Please submit this completed form at least three (3) weeks in advance of planned activity to ILCS.
Signature
Please use your mouse to sign here.
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.

1-800-961-9645
membership@ilcsonline.com