C.PetersonMay2025UIEoC
LEGAL NAME OF PARTICIPANT (Last, First, Middle Initial)
Peterson, Chantelle
AFFIRMED NAME OF PARTICIPANT (if applicable) (Last, First, Middle Initial)
Peterson, Chantelle
TITLE OF PROFESSIONAL DEVELOPMENT
Understanding Inclusion
IEIN
370160
DATE(S) OF ACTIVITY
May 31, 2025
NAME OF APPROVED PROVIDER (Enter in ELIS)
Illinois State Board of Education
REGION, COUNTY, DISTRICT, TYPE (RCDT) CODE (form is invalid without a state-approved provider RCDT code)
651088965510000
NAME OF THIRD-PARTY PRESENTER/ORGANIZATION AUTHORIZED BY A STATE-APPROVED PROVIDER ABOVE (If used)
Early CHOICES
NAME OF PRESENTER(S) (Do not enter into ELIS)
Ann Kremer
NUMBER OF PROFESSIONAL DEVELOPMENT HOURS AWARDED
2 hours
IS THIS ACTIVITY A STATE-MANDATED TRAINING?
If you answered “yes,” place a check mark next to the corresponding training listed on the chart below.
State-Mandate Training Checklist
* Optional training
Signature of Approved Provider’s Representative
June 13, 2025
Date
Signature of Participant Legal Name
Date
Signature of Participant Affirmed Name (if applicable)
Date
ISBE 77-21B (7/24)