Marygrove College Professional Development for Teachers

Participant  Information  Form  

State  Continuing  Education  Clock  Hours  Please print clearly Program Title:____________________________________________________________________________________ Start and End Dates of Session:_____________________________________________________________________ Instructor Name(s):________________________________________________________________________________ Name: __________________________________________________________________________________________ Mailing Address:_________________________________________________________________________________ City, State, Zip:__________________________________________________________________________________ Telephone Number (Area Code + Number):______________________________________Date of Birth:__________________________ School district and building:_______________________________________________________________________ E-mail Address (used for your MDE/SCR account):_____________________________________________________ Signature:_____________________________________________________Date:______________________________ How did you learn of these offerings from Marygrove College:____________________________________________

  Directions:

• Save your completed, signed and dated forms as separate pdf documents • For each course, send one (1) email with both pdf attachments to:

ed2goeducation@marygrove.edu

• Your subject line should be your last name.first name.ed2go.forms.course title. • Example: Smith.Sarah.ed2go.forms.Creative Classroom

For Office Use Only: Program Approval #:________________________________ SCECHs Earned: _____________________ Staff Initials: _______________________________________ Date: _____________________________________

To Receive SCECH Credit – Return this entire completed/signed form and the signed and dated Course Log to the Marygrove College SCECH Coordinator at the conclusion of the course. Failure to do so within thirty (30) days of the course end date will void your SCECHs.