Act 48 Request

ACT 48 REQUEST FORM
Instructors Name*
Email*
example@example.com
Phone Number
Format: (000) 000-0000.
Organization or Program providing the training
Name of Course or workshop*
Workshop LocationRoom*
(Use only the first date if a multiple day session. For additional dates see below
Initial Date of Event*

MonthDayYear
Date
Available Credit*

Act 48Act 45Other
Number of Hours Requested*
Cost
Maximum number of Participants
Description of Event
If multiple days list the session names and dates
Please add any attachments here (ie. Brochures, agenda, flyers)

Cancelof
Remember to send your attendance sheet upon completion of the training as an email attachment to the Executive Secretary for Professional Development
To receive credit, the training must meet at least one of the following PDE criteria Select the appropriate option(s) below:

Curriculum Development and Program DesignEducation in the WorkplacePDE-Sponsored course, program, etc.Early Childhood and Child Development ActivityIn-service programProfessional ConferenceReview/Redesign/Restructuring of School ProgramsSpecial Education Activity
This section in only to be completed by CPE staff
Final Approval

Clear
Date Approved

MonthDayYear
Date
Entered into Perms
Date Entered into Perms

MonthDayYear
Date
Should be Empty:

ACT 48 REQUEST FORM