CEU Request Form

Continuing Education Unit Request Form
Logistic information
Organization Name*
Event Name*
This will appear on the CEU Certificate
Event Start Date*

MonthDayYear
Date
Event End Date*

MonthDayYear
Date
Contact Person*
Contact Email*
example@example.com
Contact Phone
Please enter a valid phone number.
Event Location*
Start Time*
End Time*
Anticipated # of Participants*
Facilities and course information
Do you need any of the following from SKC? If Yes, please describe: SKC Conference and Classrooms need to be reserved through Teresa Sias: (406)275-4858
SKC Conference Rooms or Classrooms*

YesNo
Do you have a sign in sheet you prefer to use?*

YesNo
Do you have an evaluation form you prefer to use?*

YesNo
Do you need equipment from SKC?*

YesNo
Equipment Needed*
Presenter information
Presenter One
Presenter One's Name*
Presenter One's Credentials or Certifications*
Presenter One's Certificates*

Please upload as many certificates as are pertinent to teaching this course.
Cancelof
Add another presenter?*

YesNo
Presenter Two
Presenter Two's Name*
Presenter Two's Credentials or Certifications*
Presenter Two's Certificates*

Please upload as many certificates as are pertinent to teaching this course.
Cancelof
Add another presenter?*

YesNo
Presenter Three
Presenter Three's Name*
Presenter Three's Credentials or Certifications*
Presenter Three's Certificates*

Please upload as many certificates as are pertinent to teaching this course.
Cancelof
Course information
Title of sections and number of hours assigned to each section

SKC will determine the number of CEUs granted.
Section One Title*
Section One Hours*
Add another section?*

YesNo
Section Two Title*
Section Two Hours*
Add another section?*

YesNo
Section Three Title*
Section Three Hours*
Add another section?*

YesNo
Section Four Title*
Section Four Hours*
Add another section?*

YesNo
Section Five Title*
Section Five Hours*
Course outcomes and assessment
What are the expected learning objectives and outcomes?*
Examples: communication, particular skills, knowledge
How will you measure whether the participants met the expected objectives and outcomes?*
Examples: demonstrations, testing
Additional Information*
Do you have an agenda for the course you will be teaching?*

YesNo
How would you prefer to provide us with your agenda?*

Upload a fileFill it in on this form
Upload your agenda here.*

Cancelof
Fill out your agenda here.*
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Continuing Education Unit Request Form

Logistic information

Facilities and course information

Presenter information

Presenter One

Presenter Two

Presenter Three

Course information

Title of sections and number of hours assigned to each section

Course outcomes and assessment