Professional Development & Continuous Learning Certificate

REQUEST for CERTIFICATE OF COMPLETION for Professional Development / Continuous Learning Activity

Complete this form if you have completed a professional development or continuous learning activity and are in need of a certificate for license renewal or other purposes. The administrator you select below will review and certify it or contact you to discuss.
First & Last Name*
How you want it shown on the certificate (i.e. Beatrice Shoemaker)
Email*
Verified certificates will be sent to your email.
ATTENTION: Educators with an Indiana Teacher License who plan to renew their license with Professional Growth Points should review THIS CHART by the IDOE, listing the types of eligible activities and the growth points that may be counted toward eligible activities. (URL: https://www.in.gov/doe/files/pgp-experience-document-4-2020.pdf)
Name of Activity*
Details of Activity
Any additional information to assist administration in their review and certification of your request
Initial Date of Activity

MonthDayYear
Date
Number of Growth Points or Clock Hours*
Use numbers only to represent the number of points assigned to the activity or the number of clock hours.
Administrator Email Address*
Email address of admin who is able to verify and complete your certificate. DOUBLE-CHECK correct spelling of email address.
PLEASE READ PRIOR TO SUBMITTING THIS FORM TO THE ADMINISTRATOR:

AFTER submitting, a notification will be sent to the Assistant Superintendent, Mrs. Copple, at {administratorEmail}. She may complete her portion or she may contact you if more information is needed.

If Mrs. Copple completes the verification portion and submits it, you will be contacted at your email address you provided near the top of the form ({email}) with the completed certificate attached to that email as a PDF.
ADMINISTRATOR SECTION

If you are unable to verify the accuracy of the information submitted or if the information submitted needs edited to be accurate, do not go any further with this form. Instead, contact the staff member and explain why you are unable to verify and ask them to submit again with the needed information. Or, you may edit the information above to make it accurate but please be sure to communicate to the staff member what you edited and why. It will only be edited after you complete the admin portion and you click Submit.

When you submit the completed form, it will automatically notify the staff member and they will receive the completed certificate via email.
Administrator Name*
As you want it shown on the certificate (i.e. Jesse Ventura)
Administrator Title *
As you want it shown on the certificate (i.e. Principal, Scottsburg Elementary)
ADMIN INITIALS*

Clear
Initials of admin
Should be Empty:

REQUEST for CERTIFICATE OF COMPLETION for Professional Development / Continuous Learning Activity