Request
for Approval of Clock Hours
School
Nutrition Association Certification Program
Approval can take up to 4 Weeks
Submit ONE MONTH PRIOR to activity
to:
Sharon Maus MSNA or
FAX to: 320-251-2343
21997 Co. Rd 141
Kimball MN 55353
DIRECTIONS: Please type or print clearly. Please
provide complete information. Attach a brochure, registration form,
announcement, etc., publicizing the activity and the time(s) instruction will
take place. Attach additional information
(agenda, outline, syllabus, etc.) regarding the objectives/outcomes/content
of the activity if necessary.
Name of Activity: __________________________________ Sponsor: _________________________
Location: ___________________________________ Date(s) Held:___________________________
Is this activity open to food service employees from other districts? (circle one) YES NO
Type of Request: (circle one) INDIVIDUAL (yourself only) GROUP (group of people)
Requester: _________________________________________ Date:__________________________
Address: ___________________________________________________________________________
number
& street city
state
zip
Phone: W __________________________________ FAX _______________________________
| Title of Individual Session | Instructor(s) | Title and Date of Curriculum used |
Objectives/Outcomes/Content
(Attach additional information if necessary) |
CEU's Requested** |
Specialized Training Clock Hours Requested** |
|
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|
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|
TOTAL CLOCK HRS REQUESTED** _________ _________
** Break periods, mealtimes, registration, etc. must be excluded from the number
of requested clock hours.