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(267) 247-5584
1456 Ferry Road, Suite 404 Doylestown, PA 18901
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Foundations Community Partnership
Home
About
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Overview
Apply to FCP & Manage Prior Grants
Bucks Innovation and Improvement Grants
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Emergency Action Grants
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Events
#FCPresents
Partnership YeS Luncheon
Workshops
Summer Youth Corps
Scholarships
Resources
FCP Conversations Online
Key Partners & Resources
Latest News
Support
Contact
Home
About
Grants
Overview
Apply to FCP & Manage Prior Grants
Bucks Innovation and Improvement Grants
Capital Improvement Grants
Emergency Action Grants
Nonprofit Growth Grants
Partnership in Youth Services Grants
Target Funding Grants-General Operating Support
Events
#FCPresents
Partnership YeS Luncheon
Workshops
Summer Youth Corps
Scholarships
Resources
FCP Conversations Online
Key Partners & Resources
Latest News
Support
Contact
SYC PA Criminal Background Check
First Name
(Required)
Last Name
(Required)
Middle Name
Date of Birth
(Required)
Identity Theft #
Social Security Number (recommended)
Race
Sex
Female
Male
Nonbinary
Alias First Name
If you have more than one alias, please let Caroline know.
Alias Middle Name
Alias Last Name
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SYC Emergency Contact Form
Name
(Required)
Emergency Contact Person
Relationship
Best Phone Number for Emergency Contact
Secondary Phone Number
Back-up Contact Names
Please list names/phone number of any other individuals we could call in case of emergency in case your primary contact is not reachable.
Back-up Contact Names & Numbers
Health Conditions/Allergies
Do you have any allergies or health conditions that we should be aware of?
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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
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PA Criminal Background Check
First Name
(Required)
Last Name
(Required)
Middle Name
Date of Birth
(Required)
Identity Theft #
Social Security Number (recommended)
Race
Sex
Female
Male
Nonbinary
Alias First Name
If you have more than one alias, please let Caroline know.
Alias Middle Name
Alias Last Name
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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.
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Workshop Evaluation
Name
(Required)
Full Street Address/City/State/Zip
(Required)
Email Address
(Required)
Phone Number
(Required)
Certificate Sought
(Required)
Psychologist
Social Work/LPC/MFT
NBCC
General Attendance Only
Choose General Attendance Only if you are not seeking CE Credit.
I would like my CE Certificate mailed to the above address.
Yes
Otherwise all CE certificates will be emailed as PDF documents.
Please Rate this Professional Education Workshop, Items 1 - 8
Using the following scale: 4 = Excellent, 3 = Good, 2 = Fair, 1 = Poor
1. At the end of this activity, the learner will be able to summarize current telehealth standards, as well as relevant ethical concerns.
(Required)
4 Excellent
3 Good
2 Fair
1 Poor
2. At the end of this activity, the learner will be able to explain strategies for improving the delivery of telehealth-based counseling.
(Required)
4 Excellent
3 Good
2 Fair
1 Poor
3. At the end of this activity, the learner will be able to discuss recent research related to the practice of telehealth-based counseling.
(Required)
4 Excellent
3 Good
2 Fair
1 Poor
4. Please rate the expertise of the presenter, Charles Jacob, M.S.Ed., Ph.D.
(Required)
4 Excellent
3 Good
2 Fair
1 Poor
5. Please rate the appropriateness of the teaching strategies used by the presenter.
(Required)
4 Excellent
3 Good
2 Fair
1 Poor
6. Please rate the degree to which opportunities for questions/answers met your needs.
(Required)
4 Excellent
3 Good
2 Fair
1 Poor
7. Rate the ease of registration and the helpfulness of staff overseeing the workshop.
4 Excellent
3 Good
2 Fair
1 Poor
8. Please rate how well this online platform worked for you.
4 Excellent
3 Good
2 Fair
1 Poor
9. How useful was the content of this CE program for your practice or other professional development?
(Required)
5 = Extremely Useful
4 = Very Useful
3 = Somewhat Useful
2 = A Little Useful
1 = Not Useful
10. How much did you learn as a result of this CE program?
(Required)
5 = Extremely Useful
4 = Very Useful
3 = Somewhat Useful
2 = A Little Useful
1 = Not Useful
What future topics would you like FCP to present for Professional Education Workshops?
We value your comments! Thank you!
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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
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