6 CAR pt. 239, Appendix A
REQUEST TO PRESENT A TRAINING PROGRAM TO SCHOOL BOARD MEMBERS
Please compile the following information and submit it electronically via the Division's website:
http://www.arpdsam.org/
Pursuant to Section 6.03 of the Division of Elementary and Secondary Education Rules Governing Required Training for School Board Members (Rule), program providers must submit a detailed description of the entire program, including staff qualification, to the Department to be received at least thirty (30) days prior to the date of the program. This deadline will allow for review of the program to determine whether training and instruction credit pursuant to Ark. Code Ann. § 6-13-629 and this Rule may be awarded.
1.) Name and Address of Provider: ______
2.) Contact Person for Provider: Name: ______
Address ______
Phone Number: ______
Fax: ______
E-Mail ______
3.) Title and Detailed Description of Program: ______
4.) Please indicate how the program content will apply to Section 5.00, Training Content, of the Rules Governing Required Training for School Board Members
5.) Date(s) program is to be presented: ______
6.) Members of provider's staff who will provide instruction at the program:
a.) Staff Member's Name: _______
Address: _______
Phone Number _______
Fax Number: _______
E-mail: _______
List qualifications to present program (include relevant educational background, work experience, examples of similar programs presented, etc.):
b.) Staff Member's Name: _______
Address: _______
Phone Number _______
Fax Number: _______
E-mail: _______
List qualifications to present program (include relevant educational background, work experience, examples of similar programs presented, etc.):
c.) Staff Member's Name: _______
Address: _______
Phone Number _______
Fax Number: _______
E-mail: _______
List qualifications to present program (include relevant educational background, work experience, examples of similar programs presented, etc.):
d.) Staff Member's Name: _______
Address: _______
Phone Number _______
Fax Number: _______
E-mail: _______
List qualifications to present program (include relevant educational background, work experience, examples of similar programs presented, etc.):
e.) Staff Member's Name: _______
Address: _______
Phone Number _______
Fax Number: _______
E-mail: _______
List qualifications to present program (include relevant educational background, work experience, examples of similar programs presented, etc.):
f.) Staff Member's Name: _______
Address: _______
Phone Number _______
Fax Number: _______
E-mail: _______
List qualifications to present program (include relevant educational background, work experience, examples of similar programs presented, etc.):
7.) Please add to this document any other information that you believe would be helpful in assisting the Division in determining whether to grant your request.
8.) The DESE shall promptly review the content of the program for compliance with any and all applicable statutes and Division rules to determine if any or all of the program content shall be deemed to provide training and instruction credit and shall establish the time period the training and instruction provider is approved to offer the program.
9.) Upon notification by the DESE of approval of the program (or parts thereof) for training and instruction credit, the provider may enroll participants in the program and offer the program for training and instruction credit for the set time period.
10.) The provider shall be responsible for the preparation and dissemination of proof of completion of the program (or parts thereof) to all attendees. All such proofs, or copies thereof, shall be submitted by the board member attendees to the superintendent of the district whose board they serve.
Submitted by: ____ Date: ____
FOR DESE USE ONLY
Date Provider Information Received _______
Date Reviewed: _______
Request to Present Program: Approved: _______
Denied: _______
Date of decision: _______
Signature of DESE Representative: _______