Clinton School District

Flex Day Professional Development Request Form

Name:______________________________  SS#:_______________________ Date: _______________

Position: ___________________________ School/Department: _______________________________

 I hereby apply for “Flex Day” professional development leave on the following dates 

                Beginning  (first day): __________________              Ending (last day): __________________

This session will be used in lieu of attending the district session(s) on Feb. 9 _____ May 23____.

Indicate the date(s) that apply by writing in the number of hrs to be replaced by the appropriate date(s)

Please complete and submit the following information to your principal at least four (4) weeks in advance of the session to be attended and of the designated flex day to be used. The principal will forward a copy to the Assistant Superintendent for final approval. One copy will be returned by the principal to the person making the request upon APPROVAL or DISAPPROVAL. Documentation of attendance is required upon completion (see “Flex Day Guidelines” for more information).

NOTE: Approved “Flex Day” professional development hours will count toward the 60 hours of Clinton District-Wide In-service.

Name of PD Activity: ____________________________________________________________________

Location of PD Activity: ______________________________ Number of Hours of PD Activity ________

     (Be certain to attach the appropriate documentation : copy of registration form, copy of agenda, etc.)

                 Please check the PD areas that pertain to this workshop in increasing student achievement.

 □ content (K-12)                   □ systemic change process                                    □ educational technology

□ supervision                       □ standards, frameworks, & curriculum alignment         □ mentoring/coaching

□ assessment                        □ principals of learning/developmental stages               □ cognitive research

□ advocacy/leadership       □ building a collaborative learning community               □ parental involvement

                            □ instructional strategies

EVIDENCE OF CURRICULAR CORRELATION

List two (2) ways in which this PD activity can help to increase your students; academic performance.

How is this activity linked to your building’s school improvement plan (ACSIP), state content standards, or research-based best teaching practice?

SIGNATURES/DATES OF APPROVAL

Principal: __________________________________________ Date: _____________

 Assistant Superintendent: ______________________________________ Date: _________________