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. Submit proof of COVID-19 vaccination.
3. 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).
4. Submit a current resume.
Requested assignment *

Student Teaching/Internship Classroom Observation Hours
Full Name *

First Name Middle Initial Last Name
Address *

Street Address

Street Address Line 2

City State / Province

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

Month Day Year
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Social Security Number *
Note: this form uses SSL encryption for secure submission
Student teachers/interns and classroom teachers are required to be vaccinated against COVID-19. Upload a copy of your COVID-19 vaccine card. *

Note: this form uses SSL encryption for secure submission
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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.
You have not provided the required consent and, therefore, you are not eligible to complete this request form.
Subject(s) Requested *
Grade Level(s) Requested *

K 1 2 3 4 5 6 7 8 9 10 11 12
Requested Start Date *

Month Day Year
Date
Requested End Date *

Month Day Year
Date
Certification(s) Working Toward *
Sponsoring College/University *
College/University Supervisor *

First Name Last 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