PENNSYLVANIA INSPIRED LEADERSHIP INITIATIVE



0132080005448300246380REGION 700REGION 7114300029210PENNSYLVANIA INSPIRED LEADERSHIP PROGRAM“Creating Inspired Leaders at All Levels”2018-2019 Application00PENNSYLVANIA INSPIRED LEADERSHIP PROGRAM“Creating Inspired Leaders at All Levels”2018-2019 Application9525032385Please apply ASAPEnrollment is limited.00Please apply ASAPEnrollment is limited.-11747546355The number of credits/hours per course?encompasses both in-class activities and out-of-class assignments.00The number of credits/hours per course?encompasses both in-class activities and out-of-class assignments.Name of Applicant FORMTEXT ?????Title (Ms. Mrs. Mr. Dr. Fr. Sr.) FORMTEXT ?????Name to be printed on certificate FORMTEXT ?????Present Position (ex. High School Principal) FORMTEXT ?????CheckCOHORTNISL Course 1 is a prerequisite for NISL Courses 2, 3Act 48 PIL CreditsCPE HoursNo. ofDaysPILREGIONLOCATION(first session)STARTDATE?NISL Course 1A 2 Credits60 Hours87Allegheny IU37-10-18?NISL Course 1B2 Credits60 Hours87Allegheny IU310-2-18?NISL Course 1C 2 Credits60 Hours87Allegheny IU32-7-19?NISL Course 2A 2 Credits60 Hours87Allegheny IU37-17-18?NISL Course 2B2 Credits60 Hours87Allegheny IU310-9-18?NISL Course 2C2 Credits60 Hours87Allegheny IU33-13-19?NISL Course 3A2.5 Credits75 Hours107Allegheny IU38-8-18?NISL Course 3B 2.5 Credits75 Hours107Allegheny IU311-28-18?PA Coaching A1 Credit30 Hours37Allegheny IU311-8-18?PA Coaching B 1 Credit30 Hours37Allegheny IU34-4-19?Online Blended Course – Team Building & Collaboration1 Credit30 Hours7Online with one mandatory face-to-face @ IU27 (11-1-18)9-30-18?Online Blended Course – Prenatal Through Grade 3 (P3) Systems Leadership1 Credit30 Hours7Online with one mandatory face-to-face @ IU3 (11-30-18)10-7-18?Online Blended Course – Foundations: Data to Action – 1 1 Credit30 Hours7Online with one mandatory face-to-face @ IU3 (11-27-18)10-14-18?Online Blended Course – Foundations: Data to Action – 21 Credit30 Hours7Online with one mandatory face-to-face @ IU27 (3-8-19)2-3-19?Online Blended Course – Career Readiness1 Credit30 Hours7Online with one mandatory face-to-face @ Beaver County CTC (4-24-19)3-17-19YEARS AS AN ADMINISTRATOR: (Please indicate the number of years of administrative experience through June 2016.)POSITIONYEARSPOSITIONYEARSAssistant Principal FORMTEXT ????Intermediate Unit Assistant Executive Dir. FORMTEXT ????Principal FORMTEXT ????Intermediate Unit Executive Director FORMTEXT ????Assistant Superintendent FORMTEXT ????Vocational-Technical School Director FORMTEXT ????Superintendent FORMTEXT ????Other (Please list.) FORMTEXT ???? FORMTEXT ????Date Hired in Current Position: FORMTEXT ?????Were you a principal prior to January 1, 2008? If so, where and when. FORMTEXT ?????Are you a new assistant/vice principal or principal who must fulfill the Act 45 Principal Induction Program requirement? FORMCHECKBOX Yes FORMCHECKBOX NoAPPLICANT INFORMATION:Intermediate Unit FORMTEXT ?????County FORMTEXT ?????School District FORMTEXT ?????District AUN# (9 digit) FORMTEXT ?????. of Students in District FORMTEXT ?????School FORMTEXT ?????No. of Students in School FORMTEXT ?????List grades in you oversee, including pre-school programs. FORMTEXT ?????School Address FORMTEXT ?????City/State/Zip Code FORMTEXT ?????Office Phone FORMTEXT ?????Office Fax FORMTEXT ?????Home Address FORMTEXT ?????City/State/Zip Code FORMTEXT ?????Home Phone FORMTEXT ?????Cell Phone FORMTEXT ?????Email address FORMTEXT ?????EDUCATION: (Please cite most recent experience first.)UNIVERSITY/COLLEGEDEGREEDATE OBTAINED FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PA CERTIFICATES HELD: CERTIFICATEDATE ISSUED FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PRIOR ADMINISTRATIVE EXPERIENCE: Title FORMTEXT ?????Dates employed FORMTEXT ?????School District FORMTEXT ?????City, State, Zip Code FORMTEXT ?????Title FORMTEXT ?????Dates Employed FORMTEXT ?????School District FORMTEXT ?????City, State, Zip Code FORMTEXT ?????ACT 48 CREDIT:PPID Number FORMTEXT ?????What year does your current Act 48 compliance period end? FORMTEXT ????How many additional Act 48 PIL hours do you need by the end of your compliance period? FORMTEXT ????Participants will be awarded Act 48 PIL hours/CPE credits at the completion of a course. In order to receive Act 48 PIL hours/CPE credits, participants must participate in all activities and attend all sessions or make up sessions missed at their regional location or in another region. SUPERVISOR INFORMATION:Name FORMTEXT ?????Supervisor’s Title FORMTEXT ?????Supervisor’s District or School FORMTEXT ?????Office Address FORMTEXT ?????City, State, Zip Code FORMTEXT ?????Office Phone FORMTEXT ?????Office Fax FORMTEXT ?????Email Address FORMTEXT ?????STATEMENTS OF UNDERSTANDING AND AFFIRMATION:CHECK FORMCHECKBOX I understand that in order to receive Act 48 PIL hours/CPE credits for a course, I must participate in all activities and attend all sessions. In the event that I miss a day or part of a day, I will make up the session in either my or another region. FORMCHECKBOX I understand that there will be a considerable amount of preparation including prior reading assignments and, in some cases, online work for each unit. FORMCHECKBOX I understand that I will be expected to complete job-embedded activities throughout the course. FORMCHECKBOX I affirm that my supervisor: (1) supports my participation in this program; and (2) agrees to provide release time for me to attend all course sessions.REQUIRED INFORMATIONPlease return this completed application to: REGION 7IUs -- 1, 2, 3, 7, 27Nicole RubinoAllegheny IU 3 475 East Waterfront Drive Homestead, PA 15120 412-394-4637 Nicole.Rubino@ All program costs, including tuition, meals, and materials, will be paid by the Pennsylvania Department of Education except for participant mileage expenses to the course locations.Additional information may be obtained online at: 7 Complete Course Calendar can be found on our web page: ?? Call PA Inspired Leadership at 412-394-5752 or Nicole Rubino at 412-394-4637 (Nicole.Rubino@) ................
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