SECTION I:  WORKSHOP REQUEST

Host Organization:

Contact Person:

Title:

Address:

City

Zip

Phone:

Fax:

E-Mail Address:

Workshop Title/Topic 1:

Workshop Title/Topic 2

Workshop Title/Topic 3

Who is this workshop being planned for: (Please check all that apply)

o

Administrators

o

CST Members

o

Parents

o

Parent Leaders

o

Principals

o

Teachers

o

Others

Workshop Dates Requested (Please list at least three potential dates, if your dates are flexible):

Date 1

Date 3

Date 2

Date 4

Workshop Time(s) Requested:

1.

2.

3.

Duration of Workshop:

hours

minutes

Workshop Location:

Address:

City

County:

Room Number:

Floor: 

Emergency Contact for Host Organization at time of Workshop:

Emergency Phone Number:

(       ) 

SECTION II:  FOR SPAN USE ONLY:

Date Confirmed:

Time:

Grant requirement? 

oYES

o NO

Fee Amount:  $

Workshop Presenter Assigned:

Phone Number 1:

Phone Number 2:

E-Mail Address: