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    Marygrove College Professional Development for Teachers

Participant  Information  Form   State  Board  Continuing  Education  Units   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:__________________________________________________________________________________ Signature:_____________________________________________________Date:______________________________ To Receive SB-CEU Credit – Return this entire completed/signed form and the signed and dated Course Log to   the Marygrove College SB-CEU Coordinator at the conclusion of the course. Failure to do so within thirty (30) days of the course end date will void your SB-CEU’s. 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 #:________________________________

SB-CEU’s Earned: __________________________

Staff Initials: _______________________________________

Date: _____________________________________


ED2Go.MG_Participant_Information_Form