HCSD Student Teacher/Intern & Classroom Observation Request Form

Harrison Central School District

Student Teacher/Intern & Classroom Observation Request Form
Pre-service teacher certification candidates who wish to complete their student teaching/internship or observe classes in the Harrison Central School District must:
1. Submit this completed form at least 30 days before the requested assignment is to begin. Without prior approval, a pre-service teacher cannot be assigned to a student teaching/internship or classroom observation experience in the Harrison Central School District.
2. Give consent for the Harrison Central School District to access your fingerprint clearance report through NYSED TEACH (no cost) OR consent to a background check and assume the cost of the background check (approximately $150).
3. Submit a current resume.
Requested assignment*

Student Teaching/InternshipClassroom Observation Hours
Full Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Note: this form uses SSL encryption for secure submission
Social Security Number*
Note: this form uses SSL encryption for secure submission
Confidentiality Agreement
1. I understand that I may come in contact and/or have access to confidential
  information including, but not limited to, names, facts and/or information about individuals, businesses and/or families.
2. I understand and agree that the definition of confidential information includes all documentary, electronic or oral information made known to me during my placement including, but not limited to, information regarding students, employees, the school district, and/or other protected information.
3. I agree that I shall not reveal, publish, discuss, disclose or communicate such
  confidential information, directly or indirectly, to any third-party, except as explicitly authorized by the school district.
4. I agree that I will comply with the school district's policies on confidentiality and all applicable laws, including, but not limited to, the Family Educational Rights and Privacy Act.
5. I agree that I will not remove any property, documents and/or materials of any kind from the premises of the school district unless authorized as part of my duties or with the express authorization of the school district.
Are your fingerprints currently on file with NYSED TEACH and do you give consent for the Harrison Central School District to access your fingerprint clearance report.*

YES, I give consent to permit HCSD access my fingerprint report.NO, my fingerprints are not on file with NYSED and/or I do not give consent for HCSD to access my fingerprint report.
If your fingerprints are NOT on file with NYSED TEACH and/or you do not give consent for the Harrison Central School District to access your fingerprint clearance report, you must provide consent for the Harrison Central School District to conduct a background check (i.e., criminal background check, social security trace, and sex offender registry search) and you must assume the cost for the criminal background check (approximately $150).*

YES, I give consent to the background check and will assume responsibility for the cost (approximately $150)NO, I do not give consent to the criminal background check.
Subject(s) Requested*
Grade Level(s) Requested*

K123456789101112
Requested Start Date*

MonthDayYear
Date
Requested End Date*

MonthDayYear
Date
Certification(s) Working Toward*
Sponsoring College/University *
College/University Supervisor*

First NameLast Name
College/University Supervisor Email*
example@example.com
College/University Supervisor Phone*
Please enter a valid phone number.
Upload a copy of your resume*

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Harrison Central School District