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Instructor Request Form

Please complete and submit the form below. *are required fields

- All requests should be completed at least 60 days prior to the requested date of your training. You will need to have a training date in mind when submitting your request.
- While we strive to accommodate every request for training we receive, we cannot guarantee a trainer will be available for the exact requested date of your training, or if you have requested a specific trainer, that they will be available for the requested date of your training. You will be provided options in the situation your original request cannot be granted.
- Please allow us a minimum of 2-3 weeks to process your request. Once we have verified the availability of a trainer, we will prepare an agreement for your acceptance.
- Upon return of the signed agreement the date is reserved for your group and the details of your training are finalized.
- Daily rate includes 6-hours of training with an hour break for lunch (7 hours).
- If you have any questions or need further assistance, contact us at 800-842-2846.
Please check to proceed.*
- I have read and accept the terms above.

Contact Information
Organization Name*
Name*
First Last
Email*
Phone*
Phone Ext.
I have been working with the following speaker
Coordinator/manager currently working with*
Name of coordinator/manager
Hidden
Coordinator/manager currently working with*
Address*
Street Address Address Line 2 City ZIP / Postal Code
State*
Additional Information
Type of School/Organization*
Please Define
Hidden
Type of School/Organization*
- Church
- College/University
- District Office
- Head Start/Early Head Start
- Elementary School
- Faith-Based Childcare/School
- Government Agency
- High School
- Home School
- Independent Childcare
- Middle School
- Pre-K
- Private Childcare
- Public Childcare
Emergency Cell*
Billing Contact Information
Name of Person to Receive Invoice*
First Last
Organization
Billing Address*
Same as Contact Information

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email to Send Invoice*
Email of Secretary
Phone of Payer*
Event Information
Type of Event*
Event Dates*
Enter as MM/DD/YYYY. To add additional dates, use the "+" (NOTE: All requests should be completed at least 60 days prior to the requested date of your training. You will need to have a training date in mind when submitting your request.)
Proposed Start Date Proposed End Date
Hidden
Proposed Start Date
MM slash DD slash YYYY
Hidden
Date Details
Speaking Site
Site Address*
Same as Contact Information

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What is the most convenient airport to fly into?
Describe the Event
Hidden
Type of Audience*
Please select all that apply
- Administration
- Administration – Childcare
- Administration – Elementary School
- Administration – Middle School
- Administration – High School
- Assistant Director
- Before/After School Care
- Behavior Specialist/Interventionist
- Bilingual/Spanish
- Center Director
- Childcare Provider
- Classroom Aide
- Classroom Coach
- Counselor/Mental Health Professional
- Director
- Disabilities Specialist
- Disabilities Manager
- District Office
- Education Manager
- Education Specialist
- Family Engagement Staff
- Family Engagement Manager
- Foster Care Organization/Non-Profit Organization
- Health Specialist
- Health Manager
- Home Visitor
- Human Resources Specialist
- Non-Profit Organization
- Lead Teacher
- Legislature/Government Official
- Mental Health Professional/Specialist
- Middle School (6th – 8th)
- High School
- Office of Education or other State Level
- Paraprofessional
- Parent
- Parent/Family Involvement
- Private Preschool/PreK
- Program Director
- Psychology
- Public Preschool/PreK
- Resource Teacher
- Social Emotional Learning Coordinator/Administrator
- Social Work
- Special Needs
- Specialist (PE, Music, Art, etc)
- Student
- Superintendent or other District Level
- Teacher
- Teacher – Art/Music/Specialist
- Teacher – Infant/Toddler
- Teacher – Preschool/Childcare
- Teacher – Kindergarten
- Teacher – Elementary School
- Teacher – Upper Elementary
- Teacher Aide
- Teacher Assistant
- Therapist (Occupational, Speech, Physical)
- Other Not Listed
Hidden
Type of Audience
Please select all that apply
- Administration
- Teachers
- Mental Health
- Support Staff
- Family Engagement
- Parents
- District Staff
- State/Federal Government
- Other
Type of Audience*
Please describe*
Hidden
Age Group of Children
Please select all that apply
- Select All
- Infant/Toddler
- Pre-K/K
- Elementary
- Jr. High
- High School
- Administration/Staff
- Other Not Listed
Age Group of Children*
Please Describe*
Hidden
Estimated Number in Attendance
Estimated Number in Attendance*
Start Time*

: Hours

Minutes

AM/PM
End Time*

: Hours

Minutes

AM/PM
Time Zone*
I need to
- Request another type of event.
Hidden
Event Information - #2
Hidden
I have been working with the following speaker
Type of Event*
Hidden
Event Dates*
Enter as MM/DD/YYYY. To add additional dates, use the "+"
Proposed Start Date Proposed End Date
Hidden
Speaking Site
Hidden
Site Address*
Same as Contact Information

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Hidden
Describe the Event - #2
Hidden
Type of Audience*
Please select all that apply
- Administration
- Administration – Childcare
- Administration – Elementary School
- Administration – Middle School
- Administration – High School
- Assistant Director
- Before/After School Care
- Behavior Specialist/Interventionist
- Bilingual/Spanish
- Center Director
- Childcare Provider
- Classroom Aide
- Classroom Coach
- Counselor/Mental Health Professional
- Director
- Disabilities Specialist
- Disabilities Manager
- District Office
- Education Manager
- Education Specialist
- Family Engagement Staff
- Family Engagement Manager
- Foster Care Organization/Non-Profit Organization
- Health Specialist
- Health Manager
- Home Visitor
- Human Resources Specialist
- Non-Profit Organization
- Lead Teacher
- Legislature/Government Official
- Mental Health Professional/Specialist
- Middle School (6th – 8th)
- High School
- Office of Education or other State Level
- Paraprofessional
- Parent
- Parent/Family Involvement
- Private Preschool/PreK
- Program Director
- Psychology
- Public Preschool/PreK
- Resource Teacher
- Social Emotional Learning Coordinator/Administrator
- Social Work
- Special Needs
- Specialist (PE, Music, Art, etc)
- Student
- Superintendent or other District Level
- Teacher
- Teacher – Art/Music/Specialist
- Teacher – Infant/Toddler
- Teacher – Preschool/Childcare
- Teacher – Kindergarten
- Teacher – Elementary School
- Teacher – Upper Elementary
- Teacher Aide
- Teacher Assistant
- Therapist (Occupational, Speech, Physical)
- Other Not Listed
Hidden
Please describe
Hidden
Age Group of Children*
Please select all that apply
- Select All
- Infant/Toddler
- Pre-K/K
- Elementary
- Jr. High
- High School
- Administration/Staff
- N/A
- Other Not Listed
Hidden
Please Describe*
Hidden
Estimated Number in Attendance*
Hidden
Start Time*

: Hours

Minutes

AM/PM
Hidden
End Time*

: Hours

Minutes

AM/PM
Hidden
Time Zone*
Additional Information
- Any Conscious Discipline Certified Instructors within the area may attend and participate by observation at this training.
Quote
- I have received a price quote for this training.
How did you hear about us?
Please describe
Any additional information that we should know?

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