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    Marygrove College Professional Development for Teachers

Participant  Information  Form   State  Continuing  Education  Clock  Hours   Please print clearly Program Title:____________________________________________________________________________________ Start and End Dates of Session:_____________________________________________________________________ Instructor Name(s):________________________________________________________________________________ Name: __________________________________________________________________________________________ Mailing Address:_________________________________________________________________________________ City, State, Zip:__________________________________________________________________________________ Telephone Number (Area Code + Number):______________________________________Date of Birth:__________________________ School district and building:_______________________________________________________________________ E-mail Address (used for your MDE/SCR account):_____________________________________________________ Signature:_____________________________________________________Date:______________________________ How did you learn of these offerings from Marygrove College:____________________________________________ To Receive SCECH Credit – Return this entire completed/signed form and the signed and dated Course Log to   the Marygrove College SCECH Coordinator at the conclusion of the course. Failure to do so within thirty (30) days of the course end date will void your SCECHs. Directions: • Save your completed, signed and dated forms as separate pdf documents • For each course, send one (1) email with both pdf attachments to: ed2goeducation@marygrove.edu • •

Your subject line should be your last name.first name.ed2go.forms.course title. Example: Smith.Sarah.ed2go.forms.Creative Classroom

For Office Use Only: Program Approval #:________________________________ Staff Initials: _______________________________________

SCECHs Earned: _____________________ Date: _____________________________________


Ed2go marygrove college participant information form