TRENTON PUBLIC SCHOOLS



Please complete and return the following information to be placed on the ACTIVE Home Instructor list. Please type or print legibly. Email to Monique Harvey or fax to 695-6487.

|LAST NAME | |

|FIRST NAME | |

|NJ TEACHING CERTIFICATION: state as written on certificate | |

|NJ TEACHING CERTIFICATION: state as written on certificate | |

|NJ TEACHING CERTIFICATION: state as written on certificate | |

|2014-15 SCHOOL LOCATION | |

|HOME NUMBER & CELL NUMBER | |

|PRIMARY EMAIL | |

|HOME ADDRESS | |

|SPECIAL EDUCATION CERTIFICATION | YES NO |

|BILINGUAL EDUCATION CERTIFICATION | YES NO |

|EXPERIENCE WORKING WITH MEDICALLY FRAGILE STUDENT | YES NO |

|GRADE CLUSTER PREFERENCES AS PER CERTIFICATION (circle all that apply) | |

| |K-2 3-5 6-8 9-12 |

| | |

|STATE MONTH OF AVAILABILITY | |

| | |

|STATE START TIME (15 minutes after end of work day) | |

| | |

|MAXIMUM NUMBER OF STUDENTS AT ONE TIME | |

|(Circle One) |1 2 |

|OTHER INFORMATION: | |

| | |

| |

Note: Eligible Weekly Instructional Hours During Days that School Is In Session for Student and/or Staff: Health Condition (5 hrs), Special Education Placement (10 hrs), Suspension Pending Legal Hearing or Alternative Ed. Placement (10 hours), Court Order (10 hrs)

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download