Participant Initiated Non-Rid Activities (PINRA)


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This form will be used if a CMP Participant plans to attend another organization's workshop, conference, formal in-service training or activity. The RID Approved Sponsor will determine if the activity is appropriate for CEUs. Additionally, a copy of the description of the course and the Institution's transcript or grade report should be faxed, mailed, or e-mailed.

* = Required Field

* Participant Name:

* RID Member #:

* Participant Address:

* City:

*State:

* Email:

* Phone: - -

* Activity/Conference Name:

* Activity/Conference Theme or Focus: (Please mail, e-mail, or fax brochure/flyer)

* Date and Time of activity you will attend: (For multiple dates and times, please contact the sponsor for an additional document to represent your attendance to all dates of this PINRA)
Start Date:	Start Time: : am pm	End Date:	End Time: : am pm

* Total number of CEU's to be awarded: * Content Area:

MCDC-DODHH-Joy Thomassen

* I certify that this activity/conference represents a valid and verifiable Continuing Education experience that
exceeds routine employment responsibilities.

NOTE: Please mail or fax your signature for our files.

I certify I received this activity plan prior to the start of the activity/conference and I agree to sponsor this Continuing Education Experience. I will verify successful completion prior to awarding CEU's.
MCDC-DODHH-Joy Thomassen	RID Sponsor Code: 0071
Signature:	Date:

This section should be filled out and signed upon completion of the activity/conference: Activity Code Number: CEU's Awarded:
I have verified that the participant attended this activity/conference and that the activities listed are appropriate educational experiences which should be awarded the number of CEUs denoted above.
Signature:	Date: