CUSTOMIZED TRAINING INTAKE FORM
COMMUNITY-MINDED ENTERPRISES: PROFESSIONAL DEVELOPMENT
Contact Information
Name
Today's Date
-
Month
-
Day
Year
Date
Facility Name
Facility Type
Contact Person
Phone 1
Format: (000) 000-0000.
Email
example@example.com
Phone 2
Format: (000) 000-0000.
Training Information
Training Address
Desired Date(s)
-
Month
-
Day
Year
Date
Desired Time(s)
Hour Minutes
AM
PM
AM/PM Option
Are there any accommodations needed?
Last Detail Questions
1. Will you be requesting a MERIT reimbursement?
Yes
No
2. Is this a professional development day?
Yes
No
Language(s)
Number of Attendees
Number of hours wanted
Do you have any ideas for customized trainings?
PROFESSIONAL DEVELOPMENT ADMINISTRATION TO FILL OUT BELOW
Date Received from Coach
-
Month
-
Day
Year
Date
Verified Number of Attendees
Verified Date of Training
-
Month
-
Day
Year
Date
Trainers Needed
Date Contacted
-
Month
-
Day
Year
Date
PD Coordinator Signature
Coach Supervisor Signature
Title of Training
PD & CCAEW approval of MERIT template
Yes
No
Important Notes
Fee Collection specifics
Invoice Created
Invoice Sent to Provider
Invoice Sent to CME Fiscal: Date:
Reimbursement Amount: $ .00
Payment Received
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Next
COSTUMIZED TRAINING INTAKE FORM
COMMUNITY-MINDED ENTERPRISES: PROFESSIONAL DEVELOPMENT
Contact Information
Name
Today's Date
-
Month
-
Day
Year
Date
Facility Name
Facility Type
Contact Person
Phone 1
Format: (000) 000-0000.
Email
example@example.com
Phone 2
Format: (000) 000-0000.
Training Information
Training Address
Training Date(s)
-
Month
-
Day
Year
Date
Time(s)
Hour Minutes
AM
PM
AM/PM Option
Are you willing to make this training public?
No
amount of people
Last Detail Questions
1. Do you have a projector that the trainer can use?
No
Yes
2.Is there public parking? If yes, can you give specifics?
No
Other
3. Do you have adult seating and tables?
No
Yes
4. Do you have any materials? Paper, pens, sticky notes etc.
No
Yes
5. Are we allowed to take photos at this training and use them for advertising?
No
Yes
Any other information we should know?
PROFESSIONAL DEVELOPMENT ADMINISTRATION TO FILL OUT BELOW
Date Form Returned
-
Month
-
Day
Year
Date
Verified Number of Attendees
Trainer Assigned
Title of Training
MERIT Template
No
Yes
Important Notes
Public Next Steps
Flyer
Website
Roster
Certificates
Evaluations
Other
Preview PDF
Submit
Should be Empty: