STAR-Center Outreach Staff Development Request Information Sheet

Contact Person:		Telephone#:
School District/Agency:		Fax#:
Mailing Address:		Address2
County:		City:
Zip Code:		E-Mail:

Please provide pager or home phone number for contact person in the event the presenter must reach someone at the last minute - especially important for out-of town presentations:

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Please complete the following:

Service Requested:	Date Requested	Time Requested
Keynote Address (1 to 1 1/2 hrs.)
1/2 day inservice
Full day inserviceFull day inservice
Breakout session(s)
If repeating, list all times

Audience:
Anticipated # of participants:
Are you requesting a specific presenter?	Yes No
If yes, please provide name of presenter.

(Please note that we cannot guarantee the availability of the presenter requested; but will make every effort to fill your request using available staff member.) Location of Training:
(Please provide complete mailing address and attach written directions and estimated driving time when returning this request.)
Topic Area to be Addressed:


STAR-Center does not request speaker's fees; however, we do ask that districts/agencies requesting presentations provide the following: Duplication of printed material for distribution the day of the training (we will provide a copy of these materials prior to the training); reimbursement of mileage at a rate of 55 cent/mile; reimbursement of airfare, overnight accommodations, ground transportation and meals, for locations requiring these arrangements.

Please check this box if you agree to the above terms: