CEU Registration Form- Transforming

Dear Learning Forward 2015 Summer Institutes Participant;
Please fill out the top portion of the registration form and send it, your log sheet
confirming the number of requested units, and a check made out to Saint Mary’s College,
in the amount indicated on the form to:
Saint Mary’s College
Kalmanovitz School of Education
Patrice Young
1928 St. Mary’s Rd., PMB 4350
Moraga, CA 94575
The Continuing Education Unit is a nationally recognized unit designed to provide a
record of an individual’s continuing education and/or professional growth
accomplishments. Ten hours of instruction equals one (1) Continuing Education Unit.
The cost for up to one (1) Continuing Education Unit is $50.00. CEU Courses DO NOT
carry academic credit. Continuing Education Units are sometimes part of criteria used for
promotion in some school districts. Saint Mary’s College does not issue transcripts for
Continuing Education Courses.
Within two weeks after receipt of these items, I will mail a certificate to your home
address (as listed on the registration form) verifying the units you have earned. If there
are further questions, please contact me at (925) 631-4595.
Sincerely,
Patrice Young
Program Assistant
[email protected]
Registration for
Continuing Education Courses (CEU*)
(Please Print)
Name:
First
Middle
Last
Street
City/State
Zip
Address:
Email Address : _______________________________@_________________________________________
Home Phone:
Work Phone:
Course #: 823.0615
Course title: Transforming Professional Learning: Applying Proven Strategies and Tools
Date(s) of instruction: Learning Forward 2015 Summer Institutes, July 18 and 19, 2015
Instructors: Kay Psencik and Wendy Robinson
Number of CEUs for this course: 1.2 (12 instructional hours)
Fee: $60.00
These units are granted in accordance with the guidelines set by the International Association for Continuing Education
and Training (IACET).
CEU – The Continuing Education Unit is a nationally recognized unit designed to provide a record of an individual’s
continuing education and/or professional growth accomplishments. Ten hours of instruction equals one (1) Continuing
Education Unit. CEU courses DO NOT carry academic credit. Certificates are issued for Continuing Education Courses,
transcripts are not. CEUs are sometimes part of criteria used for promotion in some school districts and for license
renewal for MFTs and LCSWs.
FOR COLLEGE USE ONLY
CEU Credit is granted __________ Yes
__________ No
________________________________________________
Signature of Instructor
Fee paid:
Check:
Date:
______________________________
Date
Certificate sent on:
1928 St. Mary’s Rd., PMB 4350, Moraga, CA 94575
925-631-4595
Learning Forward 2015 Summer Institutes
Saint Mary’s College of California
Continuing Education Credit Log
2015-2016
Continuing Ed. Unit
fee is $50/unit.
This log is to record your session participation for the purpose of receiving CEU credit. Please use additional logs
as needed. Ten hours equals 1 Continuing Education Unit, five hours equals .5 Continuing Education Units.
Date/Time
Session Attended
Presenter
Hours
Total Hours
Name _____________________________________________
Home Address ______________________________________
City/State/Zip _______________________________________
Home Phone _______________________________________
E-Mail Address___________________________________
To receive Continuing Education Credit from Saint Mary’s
College, please return signed and completed log form with
registration form and payment to:
Patrice Young
Saint Mary’s College, Kalmanovitz School of Education
1928 St. Mary’s Rd., PMB 4350
Moraga, CA 94575
__________________________ ____________
Participant Signature
Date