Dear Presenter, thank you for taking the time to complete this form. The rest of the form will be completed by STAR NET. Please save a copy of this document for your records and email a completed copy of this document to your contact person so they can complete the remaining sections.


To Be Completed by Resource Specialist: Continuing Education Information
To Be Completed by Resource Specialist: Continuing Education Information (50-100 words)?
Workshop Fee: Free unless noted here.
Workshops are held in the English language.
To register: http://roe.stclair.k12.il.us/starnet
Questions about registration Call Dinnia at 618-825-3968

To be completed by STAR NET: Collaboration Information (If this is in collaboration with the ECC, please use their collaboration form. If the collaboration does not involve the ECC, please use this form.)



Agency/Collaborator Information

Agency/Program Name
Contact Person
Email Address
Phone Number
Fax Number

Workshop Details


Secure and Payment of Location (AV requirements, location arrangement/set-up, guaranteed number shared with location)
Secure and Payment of Location
Secure and Payment of Location
Secure and Payment of Location
Breakfast arrangements
Breakfast arrangements
Breakfast arrangements
Breakfast arrangements
Lunch arrangements
Lunch arrangements
Lunch arrangements
Lunch arrangements
Agency Responsible
Presenter payment
Presenter payment
Presenter payment
Handouts
Handouts
Handouts
Handouts
Other handouts (Such as regional information)
Other handouts
Other handouts
Other handouts
Number of participants/agency
Number of participants/agency
Number of participants/agency
Number of participants/agency
Providing facilitator
Providing facilitator
Providing facilitator
Providing facilitator
Registration
Registration
Registration
Registration
Confirmation letters
Confirmation letters
Confirmation letters
Confirmation letters
Name tags
Name tags
Name tags
Name tags
Evaluations and CPDUs
Evaluations and CPDUs
Evaluations and CPDUs
Evaluations and CPDUs
Attendance prizes
Attendance prizes
Attendance prizes
Attendance prizes
Give-Aways for ea. participant
Ea. participant
Ea. participant
Ea. participant
Advertise Workshop
Advertise Workshop
Advertise Workshop
Advertise Workshop
Other tasks/information
Other
Other
Other

AGENCY COLLABORATION WORKSHEET

Form is to be completed by ECC and shared with collaborating agency upon completion. All fields to be completed.

Workshop/Webinar Information



Agency/Collaborator Information


Agency/Program Name:
Agency/Program Name
Agency/Program Name
Agency/Program Name
Contact Person:
Contact Person:
Contact Person:
Contact Person:
Email Address:
Email Address:
Email Address:
Email Address:
Phone Number:
Phone Number:
Phone Number:
Phone Number:
Contact Person:
Fax Number
Fax Number
Fax Number

Presenter Information



Workshop/Webinar Details


Responsibilities Presenter Contact (Includes obtaining the following information: preferred room arrangement/set-up (e.g., rounds; 2 display tables along wall), agenda, required A/V, will presenter require sleeping room the night before, handout original to be copied)
Presenter Contact
Presenter Contact Agency who will be paying presenter fee
Location (Includes securing the following: A/V requirements with location or the person supplying, room arrangement/set-up requested, food order placed with location or outside caterer, guaranteed number shared with location)
location
Location
Secure Virtual Room (for webinars)
Secure Virtual Room
Secure Virtual Room
Facilitator (provide lunch for presenter)
Facilitator
Facilitator
CPDUs/Evaluations
CPDUs/Evaluations
CPDUs/Evaluations
Handouts (include all collaborators on the handout folders including the logo for each agency)
Handouts
Handouts
Process Registrations
Process Registrations
Process Registrations
Confirmation Letters
Confirmation Letters
Confirmation Letters
Provide Required Paperwork to workshop (sign-in sheet, CPDU forms, evaluation forms, printed name tags)
Required Paperwork to workshop
Required Paperwork to workshop
Other Tasks
Other Tasks
Other Tasks

Workshop Expenses


Payment Presenter Contract
Presenter Contract
Presenter Contract
Presenter Travel
Presenter Travel
Presenter Travel
Location Invoice
Location Invoice
Location Invoice
Miscellaneous Expenses
Miscellaneous Expenses
Miscellaneous Expenses


STAR NET Staff should complete this form only if the workshop is a WBR.



(If taking registration in database participants’ name will appear on certificates, Registration forms will need to be distributed and submitted to star net.)
(If sign in sheet is provided, participants names will not appear on certificate and will not be entered into database)
(If certificates are provided, training will automatically be submitted for SLP credit and add to list to send for IDFPR credit.)
If providing certificates is there a collaborator that needs to be listed on the certificate?      
 
if you want to take door prizes and/or a give-a-way for each person in attendance, please indicate what you would like the support staff to gather for you:
 
Please indicate what other materials you want and if they should be in the folders or not. If nothing is checked in a row, then that item is not needed.

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Address: St. Clair County ROE 1000 S. Illinois St. Belleville, IL 62220 | Phone: 618-825-3966

 

St. Clair County Regional Office of Education Lori Costello, Regional Superintendent.
Operated through a grant awarded by the Illinois State Board of Education; 100% of annual funding for the project is from federal sources.

 

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