Name of organization:

Contact person:

Job title:

Street address:

City: State: Zip:

Phone Number:

Fax Number:

Email:

Name of event:

Date of event:

Time of event: Select one morning afternoon evening weekend Other (specify):

What type of event (conference, training, inservice, other?)

Select one conference training inservice Other (specify):

Location where event will be held:

How far is the location from Minneapolis/St. Paul? miles

Topic requested for presentation: Select one Building Blocks of Literacy Training Series Monthly Reflective Practice Group - Professionals Monthly Reflective Practice Group - Supervisor Introduction to Infant Mental Health Bridging Education and Mental Health Relationship-based Teaching with Young Children Addressing Needs of Young Children Who Engage in Challenging Behavior Early Childhood Movement Get It, Got It, Go! phone consultation

How many participants will there be? Select one 1-10 10-25 25-50 50-75 75-100 100+

Who will participate?

What are the participants' level of knowledge about the topic? Select one Beginner Intermediate Advanced Mixed

What are the three to five major areas of concern regarding the topic?

1.

2.

3.

4.

5.

Will you offer a speaker/trainer fee? Yes     No

If yes, what is the fee (or the range)?

Are other speaker expenses covered?

Transportation Yes  No 

Food Yes  No 

Lodging Yes  No 

Photocopying Yes  No 

Additional Comments:

Please check to see that you have fully completed the Training Services Request form. Then click the "Submit" button to send your request and receive confirmation.