PGP and CEU Request Your Full Name(Required)Please enter it as you would like it shown on your PGP Certificate. First Last Your Email Address to Receive the PGP Certificate(Required)You will receive your PGP Certificate at this email address as a PDF attachment. If you do not receive your certificate, please check your SPAM email filter. Reach out to keepindianalearning@ciesc.org if you have trouble receiving your PGP certificate. Title / Role(Required)School CounselorSchool Social WorkerSchool Counselor LeaderSchool Behavior SpecialistDistrict AdministratorCounselor EducatorTeacherOtherPlease list your Other title / role.(Required) Name of School Corporation or Organization Title of Session(Required)As will appear on certificate Length of the Session(Required)0 - 30 Minutes31 - 60 Minutes1 - 1.5 Hours1.5 - 2 Hours2 - 2.5 Hours2.5 - 3 Hours (Half Day)3 - 3.5 Hours3.5 - 4 Hours4 - 4.5 Hours4.5 - 5 Hours5 - 5.5 Hours5.5 - 6 Hours (Full Day)Presenter Name(s)If known. Please separate multiple presenters with a comma. What is the most important thing in this session that you learned or will share with others?(Required)Date you attended/watched the session(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I am satisfied with this delivery model/method (Live session, OnDemand, etc.).(Required) Strongly Disagree Disagree Agree Strongly Agree I am satisfied with the amount of new content I learned in this session.(Required) Strongly Disagree Disagree Agree Strongly Agree How likely is it that something from today's session will impact your practice?(Required) Not Likely At All Not Likely Likely Very Likely On a scale of 1 to 10, how likely are you to recommend this session to a colleague?(Required) 1 2 3 4 5 6 7 8 9 10 Please provide any additional comments or suggestionsI am an active INSSWA member and would like to receive CEUs. Yes, I am an active and paying INSSWA member and would like to receive CEUs No, I'm not an active INSSWA member and do not need to receive CEUs PhoneThis field is for validation purposes and should be left unchanged.
