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Academic Coursework Form

Note to participant: This activity form must be submitted to the RID Approved Sponsor upon completion of the academic course. A copy of the description of the course and the Institution’s transcript or grade report should be attached. The Sponsor will enter the activity information and CEUs online at myaccount.rid.org.

Participant Name(Required)

RID Member #(Required)

Participant's Address(Required)

Street Address Address Line 2 City State ZIP Code

Participant Email(Required)

Phone(Required)

Participant Cycle End Date (if applicable)

Course Title(Required)

Name of College or University(Required)

What is the number of credit hours assigned to the course?(Required)

Please indicate whether it is per semester or per quarter

Name of Approved Sponsor(Required)

To which content area does this course apply?(Required)

Professional Studies

General Studies

Course Start Date(Required)

Course End Date(Required)

Number of Continuing Education Credits* (CEUs) awarded to CMP participant

(*1.5 CEU/credit based on a Semester session or 1.0 CEU/credit based on a Quarter session.)

As an RID member, I certify that this academic coursework represents a valid and verifiable Continuing Education experience which exceeds routine employment responsibilities.

Signature(Required)

Date Signed(Required)

Choose your payment option(Required)

Credit Card

Check - We are happy to accept a check via mail at 75 Highpower Rd, Rochester, NY 14623

Authorize.net Amount