Martinsville City Public Schools - DOC

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					                                                                                                      Forward to: Angilee Downing
                                                                                                      Assistant Superintendent of Instruction
                                                Martinsville City Public Schools
                                     Request for Approval of Recertification Points

Submitted by:                                                               School:

Name of Activity:

Sponsoring Organization:

Location of Activity:                                                       Number of Participants:
Description of Activity:
(or attach copy of activity
brochure or flyer)
                                                                                Days
 Activity Time Schedule
                                        1                2                  3                 4                 5            Additional
                                 Date             Date               Date              Date              Date               Dates
Beginning Time
Ending Time
Total Time
Less Lunch & Breaks
Total Participation Time
                                                             Total Activity Hours (must be a minimum of 5 hours)



Activity falls under the following recertification option (check one):


         Option 1 – College Credit                                              Option 5 – Publication of Book

         Option 2 – Professional Conference                                     Option 6 – Mentorship/Supervision

         Option 3 – Curriculum Development                                      Option 7 – Educational Project

         Option 4 – Publication of Article                                      Option 8 – Professional Development Activity




                              Signature                                                              Date Submitted


                    Principal/Supervisor Signature                                                         Date

               Activity Approved                                                                  Activity Not Approved
               Number of Recertification Points                                                   Option Number




         Assistant Superintendent of Instruction Signature                                                 Date

                                SUBMIT TO: ASSISTANT SUPERINTENDENT OF INSTRUCTION

                                                                                                                              HR-05 8/2012

				
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posted:10/4/2012
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