Ohio Healthy Water – Healthy People
EDUCATOR WORKSHOP PROPOSAL FORM
DateWorkshop #
(office use only)
** PLEASE ATTACH YOUR TENTATIVE AGENDA (if you have one available) **
Leader's NamePlease Ship Materials to:
Affiliation Same Address
Address Different Address Below
Name
Address
Work Phone ()
Home Phone()
FAX() Phone
Date(s) of workshopTimes
Location
CityCounty
Names of other certified HWHP Leaders helping with the workshop:
AUDIENCE: Check all that apply.
Early Childhood Teachers Preservice Teachers / College Students
Elementary Teachers College Faculty
Middle School Teachers Other Educators (e.g., youth leader, park staff, etc.)
Secondary TeachersCitizens
Administrators (Education) Other
Water Resource Specialists or Government
Agency Representatives
Estimated number of workshop participants
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FORMS--EDUCATOR WORKSHOP PROPOSAL FORM1/6/2004
Would you accept other interested persons in this workshop (you may adjust the registration accordingly)
Yes No
If yes, interested persons should call:
Name
Phone()
E-mail______
Numbers of materials needed:
HWHP Activity Guide @ $18 each
HWHP Test Kit Manual @ 12 each
______HWHP pre and post test, certificate template-FREE
Other
** IMPORTANT: PAYMENT FOR BOOKS **
After your HWHP Workshop proposal form is submitted your order for products will be filled and sent to you with an invoice for the amount of supplies ordered. Please allow 4-6 weeks for ordering and receiving supplies. After your workshop please return all unused books with full payment of used materials within two weeks.
If payment is being made by an institution please specify the name and address to which the invoice should be sent.
Please send an invoice for payment to:
** Make checks payable to: “Treasurer State of Ohio”
** PLEASE REMEMBER TO MAIL YOUR LEADER REPORT FORM TO THE HWHP PROGRAM MANAGER AFTER THE WORKSHOP (separate form)
Please fill out this form and mail to:Dennis Clement
c/o Ohio Environmental Protection Agency
Office of Environmental Education
P.O. Box 1049
Columbus, Ohio43216-1049
Telephone: (614) 644-2873
Fax: (614) 728-1275
E-mail:
The Ohio EPA and the Ohio Watershed Partnership would like to thank you for your time and effort in providing HWHP education for clean water in Ohio.
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FORMS--EDUCATOR WORKSHOP PROPOSAL FORM1/6/2004