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STAR-Center Outreach
Staff Development Request Information Sheet
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Contact Person:
_________________________________________ |
Telephone #: __________________ |
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School District/Agency:
___________________________________ |
Fax #: ________________________ |
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Mailing Address:
________________________________________ |
E-Mail: ________________________ |
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County:________________________________________________ |
City: __________________________ |
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ZIPCODE: ______________________ |
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:
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Service Requested: |
Date Requested |
Time Requested |
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( ) Keynote Address
(1 to 1 1/2 hrs.) |
_______________ |
_______________ |
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( ) 1/2 day
inservice |
_______________ |
_______________ |
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( ) Full day
inservice |
_______________ |
_______________ |
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( ) Breakout
session(s) |
_______________ |
_______________ |
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If repeating, list all times |
_______________ |
_______________ |
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Audience:_______________________________ |
Anticipated #
of participants:
______________________ |
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Are you requesting a specific presenter? |
*Yes |
*No |
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If yes, please provide name of presenter. |
_________________________________________ |
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(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.) |
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Location of Training: |
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(Please provide complete mailing address and
attach written directions and estimated driving time when returning this
request.) |
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Topic Area to be Addressed: |
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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 .365/mile; reimbursement of
airfare, overnight accommodations, ground transportation and meals, for
locations requiring these arrangements.
Please sign if you agree to the above
terms: ___________________________________________
Please fax this completed form to:
Jamey Covaleski, Administrative Coordinator,
STAR-Center
FAX: 412-687-2943
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