FCP News – Winter 2014 – Foundations Community Partnership

SYC Emergency Contact Form

Motor Vehicle Report Permission

Full Name

Date of Birth

Driver's License #

Authorization for Obtaining MVR Information

Yes

As a prospective employee or employee of FCP, I understand that FCP as part of their driver control plan will order my MVR from time to time. I understand that this report will be kept in my personnel file as part of my record. I further understand that I am entitled to a copy of my MVR upon request. Under the provisions of the Fair Credit Reporting Act, 15 USC, Section 1681 et seq., the Americans with Disabilities Act and all applicable federal, state, and local laws, I hereby authorize and permit Foundations Community Partnership or FCP’s insurance broker or commercial auto insurance carrier to obtain my MVR. I agree that a copy of this authorization has the same effect as an original.

Full Name and Date

PA Criminal Background Check

ACT 48 Assessment

Name(Required)

PDE Professional ID #(Required)

If you do not have your PDE ID#, please enter all zeros and then email your number to csinton@fcpartnership.org as soon as possible.

Full Mailing Address(Required)

School Affiliation(Required)

School District(Required)

Certification Areas(Required)

Position(Required)

I would like notification of my Act 48 credits mailed.

Yes

Otherwise, all letters will be sent via email.

Do you currently serve any students with learning or behavioral health needs addressed by this workshop?

Yes

No

If yes, how many?

Do you anticipate serving students with learning or behavioral health needs addressed by this workshop in your future professional practice?

Yes

No

Assessment

Describe Distress Tolerance and Emotion Regulation strategies that help combat anxious distress.

Describe behavioral management strategies to help support the externalizing nature of anxious distress as it can often be coupled with disruptive behaviors in children.

List concrete skills clinicians can teach and recommend to parents regarding how to manage their children’s behavioral changes in the context of their anxious distress related to the pandemic.

Host Agency Application

Agency

Agency Website

Agency Address

Contact Name

Email Address

Phone #

Agency Description/Mission

Service-Learning Opportunities & Potential Intern Assignments

Please describe the activities/duties you would anticipate for an intern. Include one to three measurable outcome goals for the internship.

Days/Hours of Agency Operations

What days/hours would the intern work most weeks?

Additional Information and/or Special Conditions or Requirements of Intern, such as regular travel between agency locations.

Intern Supervisor

Please provide name/information for one primary supervisor who will be responsible for managing the intern and communicating with FCP.

Intern Supervisor's Resume or Qualifications

Max. file size: 100 MB.

Please upload a copy of your organization's 501c3 status.

Max. file size: 100 MB.

Please upload your organization's liability insurance certificate, showing coverage for student/interns/volunteers.

Max. file size: 100 MB.

Does the organization, or any of its officers or directors have a personal, financial, or employment relationship with Foundations Community Partnership?

Yes

No

If yes, please describe the nature of this relationship:

Representative Signature

Date