BUENO EAC
Equity Assistance Center, Region VIII
Let's build
EQUITY
together
Professional Development Service Request Form

Please complete and send this form at least four weeks prior to the date of service.  Please provide a copy of your school or district’s school improvement, diversity, or equity plan with this request.  If you do not have a plan, we can help you to develop one.  All information must be provided before your request can be confirmed.  We will contact you upon receipt of the form.

Your responses will help our staff plan activitiesto acheive the objectives you desire.

If your need assistance completing this form contact our office at (303) 492-7371.



School District/Organization

   
Date
   
Superintendent/Director's Name
   
Phone
   
Contact Name
   
Position
   
School/Organization
   
Address
   
City
   
State
   
Zip Code
   
Phone
   
Fax
   
Email Address
   

Previous Professional Development offered by the Region VIII EAC
   

   
Male
   
Female
   
African American
   
Asian/Pacific Islander
   
Caucasian/White
   
Latino/Hispanic
   
Native American
   
Other
   
English
   
Language Spoken
   
Percentage
   
Language Spoken
   
Percentage
   
Language Spoken
   
Percentage
   
Male
   
Female
   
African American
   
Asian/Pacific Islander
   
Caucasian/White
   
Latino/Hispanic
   
Native American
   
Other
   
Activity
Requested Dates/Time
   
Location
   

Please complete all items below.

Participant information:
Who will participate in this training?
What are their positions in the organization?


   

Objectives:

What do you want participants to be able to do or know as a result of this training?

   

   

Need:

How did you determine this as a need?

What data did you use?

   

   

How will this training/workshop impact:

• student acheivement

• staff performance

• parent/community involvement

   

   

Measurement:

How will you document the impact of the training?

What type of data will you use?

   

   
Staff Notes: Office Use Only    

   
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