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Midwestern Intermediate Unit IV Training and Consultation Request
Please complete this form if you are seeking professional development and or support from the Training and Consultation Team.
Please direct questions to Richael Fertig, 724-287-4156 or
richael.fertig@miu4.org
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Email
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Your email
Name
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Your answer
Today's date
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MM
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DD
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YYYY
Position
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Your answer
School District/Organization
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Your answer
Phone Number
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Your answer
Type of assistance needed:
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Individual and/or small group support/consultation
Professional Development/Training
Systemic Support/Long Term Planning
Required
Topic or Content of Training and/or Support Needed
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Your answer
Please mark your preference. (subject to change)
Virtual
In person
Other:
Clear selection
If in person, location name and address:
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Your answer
Requested Date(s)
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Your answer
Time Requested
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8:30 - 11:30
12:30 - 3:30
8:30 - 3:30
Other:
Please specify details of your intentions for this training/support:
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Your answer
Anticipated number of participants:
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Your answer
Please indicate who will be participating in this training(Check all that apply)
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Special Education Teachers
General Education Teachers
K - 12
Elementary (K-5)
Middle (6-8)
High (9-12)
Administrators
Para-educators
Support Staff
Other:
Required
Please describe the training space and amenities available:
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Your answer
Will you be the point of contact on the day of the training/meeting?
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Yes
No
If not, please list a point of contact with their contact information.
Your answer
Have any MIU IV staff members been contacted directly about this training?
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Yes
No
If yes, please indicate who:
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Other information:
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A copy of your responses will be emailed to the address you provided.
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