Before the start of the activity/conference, this section should be filled out and signed by both the participant and RID Approved Sponsor:

Participant Name: _____________________________________ RID Member #: _______________ Participant Address ___________________________________________________________________ Email:______________________________________ Phone # ________________________________ Activity/Conference Name: ____________________________________________________________ Activity/Conference Theme or Focus (attach brochure/flyer) __________________________________ Date and Times of activities you will attend: _______________________________________________

Name and Code of RID Approved Sponsor ______________________________________________
I certify that this activity/conference represents a valid and verifiable Continuing Education Experience
that exceeds routine employment responsibilities.

Participant Signature: ____________________________________ Date: ___________________

I certify that I received this activity plan prior to the start of the activity/conference and I agree to sponsor this
Continuing Education Experience. I will verify successful completion prior to awarding CEUs.
Total number of CEUs to be awarded: _______ Circle content area: Professional Studies General Studies
RID Sponsor Administrator Name:___________________________Signature:___________________________
RID Sponsor Code: ___________________________Date:_______________________________

This section should be filled out and signed upon completion of the activity/conference:

Activity Code Number __ __ __ __. __ __ __ __ . __ CEUs Awarded: _______

The Participant must send documentation of attendance to the Sponsor upon completion of the activity. The Sponsor must complete and mail this form to the national office within 45 days of the completion of the activity/conference.