CUSTOM COURSE REQUEST FORM

PROFESSIONAL LEARNING - YORK U

COURSE DETAILS
Session Requested *
Board of Education
Course Title *
Potential Instructors

Maximum of 2 instructors per offering
Delivery Format *

ONLINE: No mandatory synchronous sessions

VIRTUAL BLENDED: Scheduled mandatory synchronous sessions

BLENDED: Scheduled mandatory face-to-face sessions
Registration Deadline Registration Deadline * / MM / DD YYYY

1 Week prior to start date
Maximum Enrolment

Minimum enrolment: 14 candidates
COURSE LOCATION DETAILS
School Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Do you require York University to secure a permit? *

Do you require York University to secure a permit? Yes No

Select one
Room Type Required
Other
COURSE DATES
Start Date: Start Date: / MM / DD YYYY
End Date: End Date: / MM / DD YYYY
Synchronous sessions:
Face-to-Face sessions:
Regular Meeting Day:
Start Time Start Time : HH MM AM/PM
End Time End Time : HH MM AM/PM
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Add more sessions Classes
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Saturday Sessions
Date Date / MM / DD YYYY
Start Time Start Time : HH MM AM/PM
End Time End Time : HH MM AM/PM
/ MM / DD YYYY
/ MM / DD YYYY
/ MM / DD YYYY
/ MM / DD YYYY
Add more Saturday classes
/ MM / DD YYYY
/ MM / DD YYYY
Provide further details on course dates/exceptions if required or special features:
All formats must include:

■ 100hrs of course participation and activities
■ 25hrs of Independent Learning Project (ILP) development
PAYMENT INFORMATION
Board Subsidy *

Board Subsidy Yes No
Describe the eligibility criteria for board subsidy *
Board Subsidy Amount * $ Dollars . Cents
BILLING AND INVOICING INFORMATION
Name Name * First Last
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone *

Enter numbers only
Email *
Form completed by: *
Email *
Date Date / MM / DD YYYY

CUSTOM COURSE REQUEST FORM

CUSTOM COURSE REQUEST FORM

COURSE DETAILS

COURSE LOCATION DETAILS

COURSE DATES

Synchronous sessions:

Face-to-Face sessions:

Saturday Sessions

All formats must include:

PAYMENT INFORMATION

BILLING AND INVOICING INFORMATION