Personalize this form for your conference and copy for each participant

Name of Conference or Workshop

Presentation of CEUs
Please write legibly or print information Thank you.
Name:
Daytime Phone:
Home Phone:

Email Address:

PTSB Identification Number:

ASHA Number:

(or) Last 4 digits of Social Security #

I want: (check all that apply:

ASHA
CEUs
PTSB
Credit

Please completely fill in each slot of time for attendance. If you

want ASHA credit, you MUST present to a conference check-out
person a) this sheet, b) program evaluation form, c) ASHA
Participant form and d) assessment of learner outcomes. Your
learner outcomes will be returned to you. If you want PTSB credit
from the Professional Teaching Standards board, you must return
this sheet and Program Evaluation form.
XXXday, date
Time

Session #

Total possible ASHA credits: XX

hours=0.5 credits

Credit

Speaker

Participants
Initials

Total PTSB credits XX: 7 contact

Total for the day: _________ hours

By completing this Agenda, I attest to my attendance at each workshop.

Personalize this form for your conference and copy for each participant

___________________________________________
Signature of Participant

______________
Date