1. Food Provided? NO


        CHIP FORM

        (Class, Hour, Instructor Planning and approval)

         
         


        Instructor(s) Name
        		Name  


        Work Location
        		Central Office
         

        Home Address
                 		 
         

        City
        		  


        State
        		  


        Zip
                 		 
         

        Home Phone
        		 
         

        Work Phone
        		 
            
         
        Course Name Title
        Administrator Approving this Course______________________________________________________
        Budget Authority  
        Budget #
                 		 
        * Authorizes all costs related to this class (e.g., instructors, meals, subs, materials)
         
        Class Size: Min NA Max NA
        Total Hours of Instruction (not including lunch)
                 		 
        Class Date
        		Dates
        Times
        		Times
        Class Date
        		 
        Times
        		 
        Class Date
        		 
        Times
        		 
        Class Date
        		 
        Times
                 		 
        We will cancel class automatically if minimum is not met by one week prior to the class. If you want to hold class regardless, put “0” as the minimum. We will not exceed maximum, and will automatically begin a waiting list.
         
        Location :
        		 
        Room :
                 		 
        You need to reserve room, plan for your equipment needs, set up and clean up.
        Who will provide security if needed?
                 		 
        They must have a key and know security procedures for building.



        Food Provided? NO
        Attached Food Request Approval required for snacks, meals, and drinks using district funds.
        (Cost for food and beverage should not exceed $1.50 per individual.)
         
        Credit Planned
        Please underline if you would like to offer Clock hours
        Clock hours
        		  
        ²   In District Clock Hours – Application process for instructor approval on other side – class must be 3 hours minimum, 6.5 hours maximum per day. (3 one-hour meeting times may equal one 3-hour class.)




         
        STRAND: Insert “X” beside only ONE of the course description headings for set-up on the Course Registration System .
         All  Foreign Language  On-Line
              
         Administration  General  Paraeducator
              
         Curriculum  Guidance & Counseling  SCIENCE
              
         Early Childhood  Health & Fitness  SOCIAL STUDIES
              
         English Language Learner  Language Arts  Special Education
              
         Equity & Diversity  Learning Environment  Support Staff
              
         Fine & Performing Arts  Math  Technology
        Audience:

        (e.g., All Staff, Teachers, Administrators, Invitation Only)
        Course Description: (will appear in Electronic Registrar):

        Description
        Inservice Objective/Intended Outcomes: Upon successful completion of this course, the participant will:  

        Objective and/or Outcomes  
        Prerequisites: Is the class “By Invitation Only”?
          Yes   Ã No  No
        Restrictions:      
        Registrant Type:
        		Certificated
        Classification:
        		Teacher
        Location:
        		Variable
        (E.g., Certificated, Classified)
        (E.g., Teachers-ES, Librarian, Administration, etc.)
        (E.g., North, Cascade, Whittier, etc.)
        Which state defined criteria does this class address? Check the box(es) that apply.
         
        1.
        		It is consistent with the school district’s strategic plan for improving student learning.
           
         
        2.
        		It is consistent with a school-based plan for improving student learning developed under student
          learning improvement block grants for the school in which the individual is assigned.
           
         
        3.
        		It pertains to the individual’s current assignment or expected assignment for the following school year.
           
         
        4.
        		It is necessary for obtaining an endorsement as prescribed by the State Board of Education.
           
         
        5.
        		It is specifically required for obtaining advance levels of certification.
           
         
        6.
        		It is included in a college or university degree program that pertains to the individual’s current
          assignment or potential future assignment as a Certificated instructional staff of the school district,
          where the potential of the future assignment is agreed upon by the school district and the individual.
        Instructor Qualifications
        State law requires that for each Clock Hour instructor and each class, we provide the following information:

        Academic and/or professional experience that qualifies you to teach this class, e.g., degrees and current professional position (can attach resumé, in lieu). Previous presenters enter ON FILE in this box.   

         

        ON FILE

         

           
         

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