Conference Prior Approval Request Form for Reimbursement Use this form for conferences and attach conference registration information. Form should be submitted at least 2 weeks in advance to allow sufficient time for processing Please return completed form to the SVSU Central Office *ALL INFORMATION MUST BE COMPLETED FOR PROCESSING *

Employing District

Name

School

Position

Conference Title: Conference Location: Conference Sponsor: Professional Days From

To (mm/dd/yyyy)

Conference Dates from (mm/dd/yyyy)

to (mm/dd/yyyy)

(mm/dd/yyyy)

Criteria for Conference Approval (see professional learning standards rubric included in policy #4120): Conference linked to system (SVSU K-12 Long Range Plan) and/or Building Action Plan Administrator Certification Professional Development Plan *All information on the “Criteria for Conference or Course” form must be provided in order for the request to be considered for approval.

Were you denied a course or conference this school year (July 1–June 30)? (Check if applicable) □ due to lack of funds □ due to cancellation If checked, list the date _________

Conference Cost

Estimated Cost

Registration Fee (if required, paid by participant and submitted for reimbursement) Travel at the standard IRS mileage rate. (list mileage ) Carpooling is expected. Travel other than car travel requires special permission. (Policy #4120) Meals – Maximum Per Diem expenses for Breakfast, Lunch and Dinner at the standard Government Accounting Office rate effective October 1, 2007 - $39.00 per day Lodging ( nights @ $ per night)

1

Actual Cost

Total • Proof of attendance and itemized receipts are needed for reimbursement for everything except mileage • No alcoholic beverages, tips (discretionary), personal phone calls, movie rentals, sales tax, etc. are reimbursed • Sharing lodging accommodations is expected. • Course/conference reimbursement is for tuition only: any lab fees, books, technology equipment, etc. are the responsibility of the person attending. Employee Signature

Date For Office Use Only

Date Received ____________ Assigned by supervising administrator ____________

Number of Leave Days Taken To Date___________

1st Request _______ 2nd Request _______

Principal

Date

Approved ______ Denied ______

Superintendent/Designee

Date

Approved ______ Denied ______

Conference meets criteria for horizontal movement

Date

Approved ______ Denied ______

Reason(s) for denial

Form 101A

Revised 2/2015

Criteria for Conference or Course Approval: 1. Provide district/school improvement goal (GMS) that the course/conference you are requesting meets.

2. Provide the source of evidence/data/research that will document that the course/conference you are requesting meets student needs? (Academic assessment data; SWIS data, student needs assessments, etc.)

3. How will you implement your learning from your opportunity (e.g. lesson plans, student data, share with other staff)?

4. How will you measure effectiveness of your implementation on student learning?

PLEASE ATTACH INFORMATION ON THE REQUESTED OPPORTUNITY - AGENDA, LOCATION, SPECIFIC OBJECTIVES OF WORKSHOPS THAT MEET SCHOOL GOALS.