CCML Professional Development Fund
Application for Award

CCML MEMBERS ONLY

Name:  _______________________________________________________________

Library/Institution:
______________________________________________________________________

Address:  
______________________________________________________________________

Telephone Number: ___________________    Fax Number: ____________________

E-Mail Address:  
______________________________________________________________________

Course/Program:

______________________________________________________________________

Please include a copy of the completed registration form and program 
information.

Registration Fee:  ___________________   Amount Requested:  ________________

What are your goals or expectations from attending this course/program: 

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Have you previously applied for CCML support?        Yes _________    No _________

If  yes, When?  ___________________  Was it awarded? _______________________

APPLICATION IS DUE FOUR WEEKS PRIOR TO EVENT

Signature:  ____________________________________   Date:  __________________

Please return completed form to:

Deb Weaver     
weaver.debbie@tchden.org
Clinical and Instruction Librarian
Forbes Medical Library
The Children's Hospital
1056 E. 19th Ave. B180
Ph: 303-861-6219
Fax: 303-861-6786