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Professional Learning Information Form

Contact Information

* Facilitator First Name:

* Facilitator Last Name:

* Title:

* Provider name:

Same as Facilitator

* Contact First Name:

* Contact Last Name:

* Email:

* Re-enter Email:

* Telephone:

Program Information

* Program name:

* Number of Credit Hours:

* Program Description:

* Objectives of program:

Additional Tags:

Check all that APPLY

Grade Level

Pre-School(Pre-K)

Primary(K-2)

Intermediate(3-5)

Middle(6-8)

High(9-12)

Select All

Audience

Teacher

Other Professional

District Personnel

Classified

Parent/Guardian

Principal

Counselor/School Psychologist

Kentucky Framework for Personnel Evaluation Measures

Planning

Environment

Instruction

Professionalism

Kentucky Professional Learning Standards

Learning Communities

Leadership

Resources

Data

Learning Designs

Implementation

Outcomes

*Select one of the following session type:

Asynchronous:(Session occurs at a different time)

Single Session(Learning complete in one session)

Series(Multiple sessions required)

*Please select one:

Digital

Face-to-Face

* Date

* Address

* City

* State

* Zip code:(5 Digits Only)

*Please select one:

Digital

Face-to-Face

Both

*Link	*Date
Please provide link	Please select date

*Date	*Address	*City	*State	*Zip Code:(5 Digits Only)
Please select date	Please provide street address	Please provide city name	Please provide State	Please provide Zip

Registration

Registration Deadline:

Link or directions to register:

*Special Instructions for Participants:

Yes

Enter Arrangements:

*Additional Services(Follow-up, support, etc.):

Yes

Enter Services provided:

*Registration, Material and Other fees:

Yes

Enter Possible costs:

Previous user Reference

Name:

E-mail:

Telephone:

Additional information:

*Also submit a proposal for Effective Instructional Leadership Act(EILA) credit?

Yes

If you know the EILA program, select from the list provided and click submit. Otherwise, select "Proceed to EILA form" and fill in the requested information.

*EILA Programs List:

*1.Professional Learning Standards

I recognize the Professional Learning Standards listed below and agree to align my professional learning session to meet these standards

Learning Communities: Professional learning that increases educator effectiveness and results for all students occurs within learning communities committed to continuous improvement, collective responsibility, and goal alignment.
Leadership: Professional learning that increases educator effectiveness and results for all students requires skillful leaders who develop capacity, advocate and create support systems for professional learning.
Resources: Professional learning that increases educator effectiveness and results for all students requires prioritizing, monitoring and coordinating resources for educator learning.
Data: Professional learning that increases educator effectiveness and results for all students uses a variety of sources and types of student, educator and system data to plan, assess, and evaluate professional learning.
Learning Designs: Professional learning that increases educator effectiveness and results for all students integrates theories, research and models of human learning to achieve its intended outcome.
Implementation: Professional learning that increases educator effectiveness and results for all students applies research on change and sustains support for implantation of professional learning for long term change.
Outcomes: Professional learning that increases educator effectiveness and results for all students aligns its outcomes with educator performance and students curriculum standards.

By clicking the submit button below, the application will be submitted to Professional Learning Bulletin Board for review and posting.