Revised August, 2015
Lansing Community College
Continuing Education Department
Participant Information Form
State Continuing Education Clock Hours (SCECH)
Please print clearly
Program Title: ____________________________________________________________________________
Start Date (mm/dd/yyyy) ______________________ End Date (mm/dd/yyyy) _______________________
Instructor Name(s): ________________________________________________________________________
Your Name _______________________________________________________________________________
Mailing Address ___________________________________________________________________________
City, State, Zip+4 __________________________________________________________________________
Telephone Number (Area Code - Number) ___________________________ Date of Birth __________________
School District and Building _________________________________________________________________
Email address ____________________________________________
MANDATORY: MUST be the same as SCR account email
PIC ____________________________
MANDATORY: MDE-issued Personal Identification Code
Signature ______________________________________________________ Date ___________________
To Receive SCECH Credit - Return this entire completed form and signed and dated Course Log to the LCC SCECH
Coordinator at the conclusion of the course. Failure to do so within 15 days of the end of the course may void your
SCECHs. CEUs will be uploaded to the Secure Central Registry the week following the applicant’s paperwork arrives.
Mail with Signed, Dated Course Log to
ATTN: Carolyn Dembowski, LCC SCECH
6000W Continuing Education
Lansing Community College
PO Box 40010
Lansing, MI 48901-7210
For SCECH Coordinator Use Only
Course Log Hours @ 24 + Y N
Progress Verified Y N
Final Exam 80% Y N
Date Received ______________________
MDE Approval #_____________________
SCECH Earned ____________________
SCR Upload Date ____________________
Coordinator Initials ____________
Date __________________
click to sign
click to edit