PD Provider Form » New Jersey Education Association

The application will be reviewed by the NJEA Professional Development Institute. If approved, a short description will be placed in the Showcase column of the NJEA Review publication as well as on our website. It must be submitted 120 days prior to registration deadline for the NJEA Review and website, or 60 days prior to registration deadline for posting on the website only.

For questions

Login to Contact Rich Wilson

or call 609-599-4561, ext. 2262, or

Login to Contact Vicki Serreino

or call 609-599-4561, ext. 2349.

Title of workshop/conference/course

Event Name*

Date*

Location

Registration Information

Name*

First Last

Email*

Phone*

Fax

Registration fee $*

Payable to

Registration begins

Registration ends

Online registration*

Yes
No

Web Address

Organization Information

Name of sponsor / organization

Contact Person

First Last

Business address

Street Address Address Line 2 City State ZIP Code

Email

Website

Phone

Fax

Event Information

Target audience

Grade level(s)

Instructional/Content Area

Is the activity appropriate for release time?

Yes
No

Will the activity be held outside of school time?

Yes
No

Will the workshop or participants be recorded in any way?

Yes
No

Would you be willing to sponsor a member of the NJEA Professional Development Committee to participate in your event?

Yes
No

Will there be any other materials sold at the event?

Yes
No

The sponsoring organization is

Profit
Non-profit

Attachments

Please attach any documentation with your application such as

Synopsis of program content/agenda
Conference speakers and topics
Pictures (Presenters/past conferences)
Promotional materials

Upload files

Drop files here or

Other

Explain what provisions are available

Facilities are handicap accessible?

Yes
No

Comment

Will snacks and/or meals be available?

Yes
No

Comment

Can special dietary needs be met?

Yes
No

Comment

Activity checklist

Check all that apply

Other (please specify)

Activity Data

Please complete the following

Describe the purpose/content of your activity in 200 words or less

Explain how your event relates to the New Jersey Student Learning Standards

Describe your process for self-evaluation

Would you be willing to make the results of that evaluation available to NJEA?

Yes
No

Agreement

I certify that the activity for which endorsement is sought is consistent with the spirit of Association policy and programs. I agree that the sponsoring organization

will distribute certificates to each participant for Professional Development hours, if applicable.

(enter hours)

Title of Sponsoring Organization

Please note

The questions on this application help the Professional Development Committee obtain a better understanding of the provider and the program being submitted and do not necessarily disqualify an applicant.

Signature