Clock Hour Application Form
 
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  Capital Region ESD 113 is streamlining its process for application for Clock Hours. In an effort to be more efficient and consistent, we are requiring that all applicants complete their application using this survey. Your application must reach us 10 days in advance of any offering so that we can approve it and have it listed in on our website.

Note: This form is only for approval of clock hours for a course. If you are applying to receive clock hours from a course you have taken, go to http://www.myesd.org.
   
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Session 1  
Session 2  
Session 3  
Session 4  
Session 5  
   
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Must total the number of hours the class meets, excluding meal times. A minimum of three hours is required for clock hour approval. Round down to the nearest half hour.
 
   
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All instructors must have an approved vita on file. Please see link for creating vita if the instructor is not already approved.
 
   
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If not, a vita for each person must be received before clock hours can be approved.
 
   
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Agenda shall specify topics to be covered, days and times of each presentation.
 
    
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Agenda Item 2   
Agenda Item 3   
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Agenda Item 5   
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Agenda Item 9   
Agenda Item 10   
   
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Instructor 1  
Instructor 2  
Instructor 3  
Instructor 4  
   
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Check all that apply.
 
  
  
  
  
  
  
  
  

    
   
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Note: Participants may not earn both clock hours and credit for the same course.
 
Note: Participants may not earn both clock hours and credit for the same course.
   
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Typing your full name in this box serves as your digital signature.
 
   
 
 
 
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