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| Last:
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| Title:
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| Email:
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| School:
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| District:
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| Address:
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| City:
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| State:
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| Zip:
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| Day Phone:
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(e.g.
555-555-1212 x1234) |
| Evening Phone:
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| Fax:
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| To meet our school or district goals, we need: (Please check all
that apply) |
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| I am interested in professional development with the following
Heinemann author(s) or based on the following authors' work: |
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| I would like professional development on the following topic(s): |
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| I am interested in professional development delivered in the
following formats (Comment on the best time of year, dates, or blocks of time,
as well as live support, phone/video conference, or online formats): |
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| Tell us more about your school/district |
Our school/district is characterized by:
(Comment on demographics such as student population, student/teacher ratio,
number of teachers, grade level configuration, etc.) |
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Our staff is characterized by:
(Comment on experience of teachers, areas of strength, and areas they would
like to develop.) |
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In the last 3-5 years we have focused our profesisonal development
on the following areas:
(Comment on both past and current initiatives, as well as delivery formats.) |
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| We have identified the following professional development needs in
our school/district going forward: |
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| We plan to address these needs by: |
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We have committed the following resources to professional
development:
(Comment on allocated time, funds, human resources, technology, etc.) |
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| Please provide any additional information you'd like us to have
about your school/district or professional development needs and preferences. |
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