Professional Development Request Form

For "other" please use description field below to specify.

Contact Information

Please complete all fields.
Include multiple dates for the same topic or consecutive dates if applicable.
Beginning and ending times may vary by district.
Please provide specific details describing your perception of the topics and content that should be covered during this training/workshop.
Please specify HOW this training addresses the SIP or Corrective Action Plan. This information will be used by our consultants to address critical needs.
The value must be between 1 and 100, inclusive.
(i.e. high school office, district admin bldg - Room 101, elem school - Library, etc) PLEASE BE SPECIFIC*
Please provide the physical address and phone number of the training site. This information will be provided to the trainer. Thank you.
On the day(s of training, who will serve as the Point of Contact (PoC) for the trainer? (i.e. Elem. Principal, Superintendent, Math Dept. Chair, etc.) Please include the PoC's NAME and E-MAIL address.
Have any BLaST IU 17 Training/Consultation Personnel been contacted directly about this training? If so, please provide the staff member's name.
For "other" please use description field below to specify.

Questions

Please direct any questions to Christina Reed, (creed@iu17.org) Director, Professional Learning & Curriculum Development. Phone: 570-323-8561 x1071 Fax: 570-323-1738.