Name: Last/First

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* 1. Name: Last/First

I am a contract elementary teacher with the UCDSB (not on recall) and therefore a member of the ETFO-UCL.

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* 2. I am a contract elementary teacher with the UCDSB (not on recall) and therefore a member of the ETFO-UCL.

School/worksite:

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* 3. School/worksite:

UCDSB Employee number:

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* 4. UCDSB Employee number:

School/work site telephone:

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* 5. School/work site telephone:

School/work site fax:

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* 6. School/work site fax:

Email Address:

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* 7. Email Address:

Email Address confirmation:

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* 8. Email Address confirmation:

Professional Activity:

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* 9. Professional Activity:

Title of Activity or Course:

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* 10. Title of Activity or Course:

Activity Provider:

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* 11. Activity Provider:

Beginning Date:

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* 12. Beginning Date:

Date / Time
Completion Date:

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* 13. Completion Date:

Date / Time
Funding Request - (A maximum of $750, including the OT costs, will be provided. Please estimate other costs to their predicted maximum). 

Registration Fee:

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* 14. Funding Request - (A maximum of $750, including the OT costs, will be provided. Please estimate other costs to their predicted maximum). 

Registration Fee:

Accommodation Fee

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* 15. Accommodation Fee

Car Travel: (km X $0.50)

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* 16. Car Travel: (km X $0.50)

Other Travel: (train/plane/taxi)

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* 17. Other Travel: (train/plane/taxi)

Meal Costs: (max. $80/day)

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* 18. Meal Costs: (max. $80/day)

Parking Costs:

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* 19. Parking Costs:

Other Expenses: (with explanation)

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* 20. Other Expenses: (with explanation)

Occasional Teacher Required:

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* 21. Occasional Teacher Required:

I have read the Terms of Reference on the ETFO-UCL website:
http://www.etfo-ucl.on.ca/profdevfund.html :

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* 22. I have read the Terms of Reference on the ETFO-UCL website:
http://www.etfo-ucl.on.ca/profdevfund.html :

Required Notification: Once approved, your principal will be notified of this activity if it occurs during the instructional day.

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* 23. Required Notification: Once approved, your principal will be notified of this activity if it occurs during the instructional day.

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