Monroe School District
200 East Fremont Street Monroe, WA 98272 360-804-2500
WASHINGTON STATE CLOCK HOUR REGISTRATION FORM
This form will verify your attendance at the inservice/workshop/conference offering outlined in Section II below. It will be used to document attendance
for potential movement on the LEAP schedule and for the 150-clock hour requirement. Clock hours can only be used for certification if you already hold
a continuing certificate. This form must be retained by the individual as verification of attendance. It is the individual's responsibility to maintain
accurate records for compliance with certification regulations. (Do not use this form if you are enrolling in this class/workshop for college credit)
SECTION I - PARTICIPANT INFORMATION Please Print and Use Dark Pen Only
Legal Name: (Last, First, Middle)
Maiden or Former Name:
Home Address: (Street, PO Box)
(City, State, Zip)
Work Location
Date of Birth (M/D/Y) Home Phone
( )
Work Phone
( )
SECTION II - WORKSHOP INFORMATION
Class/Workshop Title
Instructor Name
In-service #
01-009
Dates of Class
Clock Hour Provider
Monroe School District
SECTION III – AFFIDAVIT
I, _
_____________________________, swear/affirm that I earned ___24_ of _________ clock hours for actual attendance
at this workshop. I am not applying for college/university credit for this class/workshop. I certify (or declare) under penalty of
perjury under the laws of the State of Washington that the foregoing is true and correct. The intentional misrepresentation of
material fact in this form subjects the holder to revocation of his/her certificate pursuant to Chapter 180-85 WAC.
___________________________________________ $______
87.00
_____________ _________________________
Signature of Participant Amount Paid for Clock Hours Date
SECTION IV – VERIFICATION
When signed by approved workshop sponsor or instructor at closing of the in-service/workshop/conference, this form documents eligible
credits as required by WAC 392-121-280(2).
___________________________________________ _________________________
Signature of Workshop Sponsor or Instructor Date
Clock Hour Request Approval Form for Salary Increments
State Defined Criteria: In compliance with Engrossed Substitute House Bill 1410, Chapter 18, Laws of 1995 and WAC 392-121-262,
the credits earned by certificated instructional staff after September 1, 1995 shall be counted towards allocations only if the content of the
course(s ) meets any one or more of the following:
A. School-based plan in which the individual is assigned; or
B. Current assignment or expected assignment for the subsequent school year; or
C. Obtaining an endorsement; or
D. Obtaining advanced levels of certification; or
E. Degree program
F. It addresses research-based assessment and instructional strategies for students with dyslexia, dysgraphia, and language disabilities
when addressing learning goal one under RCQ 28A.150.210, as applicable and appropriate for individual certificated instructional
staff.
Employee Signature: ____________________________________ Date: _______________ Criteria ___________
(Write Criteria letter here)
Human Resources Signature: _____________________________ Date: ______________ Approval ___ Yes ___ No
Criteria changed to _________
Z:\Shared Files\Shared Folder\Forms & Labels\Credits-clock hours\Clock Hour Form - Monroe.doc
