REQUEST FOR ATTENDANCE AT CONFERENCE/SEMINAR

If you are eligible for educational days and are interested in attending a conference/seminar, please submit this completed form along with a copy of the program information to your immediate supervisor for approval prior to registering for the program.

Approval of attendance at the program is dependent upon your eligibility for educational days, the relevance of the program to your job duties, and availability of staff coverage for provision of patient care needs.

Requests for educational days should be submitted prior to the posting of the Time Schedule. If this is not possible (e.g. due to the late arrival of program information) and you are already scheduled to work on the day you are requesting off, finding your own replacement for the shift will improve your chance of approval for the educational day.

Employee Name:___________________________________ Date:___________________

Status (circle one): Full-Time RN Part-Time RN Full-Time LPN Part-Time LPN

Title of Program:________________________________________________________________

Purpose for attending this program:_________________________________________________

______________________________________________________________________________

Program Sponsor:_______________________________________________________________

Location of Program:____________________________________________________________

Are CEU's Provided (circle one): Yes No Cost of Program:______________________

Program Date(s):_______________________ # of educational days requested:__________

**Attach a copy of Program Information/Brochure**

Supervisor Use: (check one)

� Request Approved. # Days Approved:________

� Request Denied. Reason:______________________________________________________

Employee Notified - Date:_______________________

Comments:____________________________________________________________________

Supervisor Signature/Date:________________________________________________________