2024-2025 MMSD Private & Parochial Schools PD, Service Agreement and Stipend Request Form

Private & Parochial Professional Development, Service Agreement and Stipend Request Form

For the 2024-25 School Year, you will have two options for registration. MMSD can register you or you can register yourself and seek reimbursement after the event occurs. If MMSD is registering you, we need this request 4 weeks prior to the event. If you are registering yourself, we need this request request 2 weeks prior to the event. MMSD must set up the contract for any contracted services.
What type of Professional Development Request is this?

Conference or CourseHiring a consultant for Professional Development or TrainingStipend Work
Complete one Jot Form for each class/conference/activity/contract that you are requesting.

If this course, conference, activity ends after June 30, 2025, please contact Stephanie (sadankert@madison.k12.wi.us)
Attendee's Full Name*

First NameLast Name
Attendee's E-mail*
example@example.com
How is the registration being made?*

MMSD will register me (this request is being made at least 4 weeks prior to the event). Please note that if there is login information needed to register you, you will need to come to the Doyle Administration office to log in to your account).I will register myself and seek reimbursement after the event (this request is being made at least 2 weeks prior to the event).
Professional development that is paid for by federal funds, must be part of the teacher's broader professional plan to be considered high quality professional development. By marking Yes, you are assuring MMSD that this conference/professional development opportunity is part of your professional plan.*

YesNo
Grant Funding Source. (Title II-A can only be used for professional development for classroom teachers, principals and instructional leaders. Counselors, librarians, etc. can utilize Title IV-A funds for professional development.) *
Private / Parochial School *
What is the attendee's position at the above private school? (Title II-A can only be used for professional development for classroom teachers, principals and instructional leaders. Title IV-A funds for professional development can be used for counselors, librarians, classroom teachers, principals, etc.)*
Phone Number*
Home Address (for reimbursement purposes)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of requested activity (one activity per form)*
Location of Activity*
Website Link for Class/Conference/Professional Development*
Start Date of Activity*

MonthDayYear
Date
End Date of Activity*

MonthDayYear
Date
Does this Professional Development have a religious component? If yes, you be reimbursed for only the secular portion of the conference. (The PD must be at least 50% secular)*

YesNo
If there is a religious component, what percent has a religious component?
Have you seen your school's Needs Assessment?*

YesNo
On your school's Needs Assessment, indicate which Professional Development need is related to this professional development. See your school's administrator for your school's approved Needs Assessment to know which need is associated with your professional development request.*

Need #1Need #2Need #3Need #4
Describe the rationale for attending this professional development how how it is linked to your school's Needs Assessment*
Provide detailed information on the content of the professional development and the expected outcomes *
Provide the total number of participants from your school attending*
Will you be traveling for this event? Travel is only allowed for in person courses/conferences.*

Yes - You will receive a follow up JotForm and instructions for travel arrangements.No
What type of travel expenses are required?*

Hotel (Is only allowed if the conference location is greater than 50 miles from the school you work at.)MileageAirfareMeals (based on the federal per diem amount for conference location)No travel is neededOther
MMSD uses the https://www.gsa.gov/travel-resources website to calculate your meals while you are traveling for the professional development. Please use this link to calculate your meal per diem. Print this page for reimbursement purposes.
Registration cost*
Do you have a membership that would give you a discount? If yes, we will work with you for needed information or will ask that you come to the Doyle Administration Building to log into your account.*

YesNoN/A
Travel costs (airfare, hotel, milage, meals, etc.)*
School Administrator's Name *
School Administrator's Email Address*
My School's Administrator has approved this request*
Full Legal Business Name of Consultant/Vendor*
Contact Person for Consultant/Vendor*
Email of Consultant/Vendor*
Detailed Description of Provider's Service*
Number of Teachers Impacted by this Service Agreement? *
If service agreement needs individual names and emails for the service, please include them here. If individuals do not need access, write N/A.*
State Date of Service*

MonthDayYear
Date
End Date of Service*

MonthDayYear
Date
Detailed Cost of Service (amount per hour or per day). Example: $100/day for 10 days. *
Describe additional expenses (registration, meals, mileage, supplies, etc.)*
Total Amount of Contract*
Start date for Stipend Work

MonthDayYear
Date
End date for Stipend Work

MonthDayYear
Date
Describe when and where the work will be completed.
Does this work have a religious component? If yes, you be reimbursed for only the secular portion of the conference. (The work must be at least 50% secular)*

YesNo
If there is a religious component, what percent has a religious component?
Describe the work that will be done and how it relates to your Needs Assessment
Names and Emails of Staff involved in Stipend Work
Total number of hours per staff member that is being requested
Attach a Copy of the Quote, Details of Agreement and/or W-9 of Vendor

Cancelof
Should be Empty:

Private & Parochial Professional Development, Service Agreement and Stipend Request Form

Complete one Jot Form for each class/conference/activity/contract that you are requesting.