Professional Development Request Form

Please use this form to request AfterSchool KidzLit and/or AfterSchool KidzMath workshops as described in those Implementation sections.

To request a workshop, fill out the following information and press the SUBMIT button. Please complete this form once for each event you are requesting.

Fees
Daily rate (40 max. participants per staff developer): $2,000 plus travel expenses. A purchase order is required to secure this request. Discounted daily rate for community-based organizations (40 max. participants per staff developer): $1500 plus travel expenses. Note: If you have more than 40 participants, please note in the comments section, and we will contact you.

If you have any questions, please contact Hannah Portello-Swagel at 1.800.680.0290 (x320).

*=Required information *Today’s date Unknown Client Information Workshop Location (if different) *Contact first name Location contact first name *Contact last name Location contact last name *Contact title Location contact title *Organization Location organization *Address 1 Location address 1 Address 2 Location address 2 *City Location city *State Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ------- Guam Puerto Rico ------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Location state Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ------- Guam Puerto Rico ------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon *Zip code Location zip code *Work # Location phone Mobile # Home # *Primary phone Please select: Work Mobile Home *Fax *Ship to: Please select: Client address Workshop location *E-mail Workshop Type (submit one form for each type) *Format Please select: Six-hour KidzLit Six-hour KidzMath Six-hour Combination Three-hour KidzLit Three-hour KidzMath Other If “other,” specify *Preferred start date Alternative start date *Preferred end date Second alternative start date *Start time 1 2 3 4 5 6 7 8 9 10 11 12 : 00 15 30 45 AM PM *End time 1 2 3 4 5 6 7 8 9 10 11 12 : 00 15 30 45 AM PM *Number of schools/sites participating: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Schools/sites names: *Total workshop participants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Maximum number of participants = 40 Note: If you have more than 40 participants, please note in the comments section, and we will contact you. Student Population Data Total students receiving program Workshop Participants *Administrators 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 *Site Directors 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 *Leaders 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 *Volunteers 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 General information *How did you hear about us? Please select: Attended a workshop Previous purchases Conference attended Colleague referred me Mail received Link from another site Web search Other Do you care to join our mail list? (e-mail and print) Yes, please No, thanks Comments We respect your privacy and do not sell our contact names to anyone. You may review our privacy policy posted elsewhere on this site. Please note above if you would like to receive future mailings and offers about our programs and services. Press Submit to send your workshop request. Submit one form per workshop. Press Clear to erase all above information and re-enter. If you experience any problems with this form, please send an e-mail to webmaster@devstu.org.