PBS Teacherline

Professional Learning Program

Application for Professional Learning Unit Credit

Prior Approval Form

 

 

Participantís Name:†† ††††††††††† _________††††††††††††††††† ††††††††††† ††††††††††† ____ _ ††††††††††††††††††††††† †††††††††††

 

Home Address:††† ††††††††††† ††††††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† †††††††††††††††††††††††

 

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School System: ††††††††††† ††††††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† †††††††††††††††††††††††

 

Certification Type:††† ††††††††††† ††††††††††††††††††††††† ††† Position:†††††††††† ††††††††††††††††††††††† †††††††††††††††††††††††

 

Date of Birth:††† ††††††††††† ††††††††††† ††††††††††††††††††††††† ††† Social Security #:†††††††† ††††††††††† †††††††††††††††††††††††

 

Name of Course: _________________________________________________________††††† ††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† †††††††††††††††††††††††

Check the categories for which this PLU credit applies:

 

q       Field(s) of Certification

q       School/System/Individual Improvement Plan

q       Annual Personnel Evaluation

q       State/Federal Requirements

 

Description of Course:

 

 

 

 

Location of Course:††††††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† †††††††††††

 

Dates of Course:††††††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† †††††††††††

 

I hereby approve this personís participation in the above named Professional Learning Unit Credit Program.I further certify that the goals and objectives of this course are consistent with the goals and improvement objectives of this school system.

 

 

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System Superintendent or††††††††††††††††† ††††††††††††††††††††††† ††††††††††† Date of Approval

Professional Learning Coordinator

 

Iím not employed in a public or private school.

 

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†††††††††† Signature of Participant

†††††††††††† Date of Approval