MIP B.1

Name*

First Middle Last

Your Email*

Enter Email Confirm Email

School Name*

Phone*

Expiration Date

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*

Please enter the date the workshop begins, or the date that you will begin the course (if online).

Date workshop ends:*

Time Workshop Begins*

:

Time workshop ends*

:

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.

MIP B.1 Outside Association