ERROR:
JavaScript is not enabled. You must enable JavaScript in your browser to use this form
Please fill in a valid value for all required fields
Please ensure all values are in a proper format.
Are you sure you want to leave this form and resume later?
Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.
Save and Resume Later
Save and get link
You must upload one of the following file types for the selected field:
There was an error displaying the form. Please copy and paste the embed code again.
Apply Discount
You saved
with code
Submit Form
Submitting
Validating
There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.
Please check the field:
Fields
Colonial IU 20 External Agency Contractors/Interns &
Student Teachers/Observers Credentials Form
This form is to be completed for any individuals providing services under an agency, completing internships, student teaching assignments,
or observing in Colonial Intermediate Unit 20 Programs.
Name
*
First Name
*
Last Name
*
Purpose of your presence in the CIU-20 classroom
*
Building and Grounds
Fieldwork (occupational therapy)
Home Health Aide
Internship
Observation
Registered Nurse
Student Teaching
Therapeutic Field Trips
Therapeutic Field Trips (Resolve)
Name of Nursing Agency
*
Around the Clock Nursing
Bayada - Allentown
Aveanna - Allentown
Aveanna - Bartonsville
Bayada - Bartonsville
BrightStar Care of Stroudsburg & Allentown
CareSense Home Health Care
Extended Family Care
EZ Kids Care
Maxim - Allentown
Maxim - Wilkes Barre
Preferred Home Health Care and Nursing Services
Traditional - Home Health
Other Nursing Agency
Email
*
Name of Agency or University
List other nursing agency
*
Phone
*
Will you be in a classroom for 10 hours per week or more
*
Yes
No
Job Title
*
Supervisor's Name
*
First Name
*
Last Name
*
Supervisor's Email
*
Supervisor's Phone
*
Student's Name (if known)
First Name
Last Name
Certifications and or Licenses
Nursing License for RN's & LPN's
*
No File Chosen
File uploads may not work on some mobile devices.
Date of RN LPN License
*
https://colonialintermediateunit20.formstack.com/forms/images/2/calendar.png
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
Mandated Reporter Certificate
*
No File Chosen
File uploads may not work on some mobile devices.
Mandated Reporter
Date of issue Mandated Reporter Certificate
*
https://colonialintermediateunit20.formstack.com/forms/images/2/calendar.png
Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
FBI Federal Background Clearance
*
No File Chosen
File uploads may not work on some mobile devices.
FBI Clearance
Date of issue FBI Federal Background Clearance
*
https://colonialintermediateunit20.formstack.com/forms/images/2/calendar.png
Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
PA State Criminal History Clearance
*
No File Chosen
File uploads may not work on some mobile devices.
PA Criminal History
Date of issue PA State Criminal History Clearance
*
https://colonialintermediateunit20.formstack.com/forms/images/2/calendar.png
Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
PA Child Abuse Clearance
*
No File Chosen
File uploads may not work on some mobile devices.
PA Child Abuse
Date of issue PA Child Abuse Clearance
*
https://colonialintermediateunit20.formstack.com/forms/images/2/calendar.png
Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
PDE 6004 Arrest & Conviction Form
No File Chosen
File uploads may not work on some mobile devices.
TB Test Results
*
No File Chosen
File uploads may not work on some mobile devices.
Please upload a state issued photo id
*
No File Chosen
File uploads may not work on some mobile devices.
Location and Program
Please choose the site location(s) you will be working/observing at.
Bangor High School
Bangor Middle School
BF Morey Elementary
Broughal
Cheston Elementary
Chipperfield Elementary 2
Clearview Elementary
Clear Run Elementary
Clear Run Intermediate
Colonial Academy
Colonial Early Learning Center
East Hills Middle School
Kenneth Butz Elementary
East Stroudsburg High South
Easton High School
Easton Middle
Farmersville Elementary
Fork Elementary
Freedom High School
Freemansburg Elementary
Governor Wolf Elementary- (Marvine Elem 2)
Washington Elem 2 - Was Five Points Elementary
J.T. Lambert Intermediate
J.M. Hill
Lehigh Elementary
Liberty High School
Lincoln Elementary
Marvine Elementary
Middle Smithfield Elementary
Nazareth Intermediate
Nazareth Middle School
Nitschmann
Northampton Senior High
Northeast Middle
Palmer Elementary
Pocono Mt East High School
Pocono Mountain West High School
Pocono Mountain West Junior High
Pleasant Valley High School
Pleasant Valley Intermediate
Pleasant Valley Middle
Resica Elementary
Saucon Valley Elementary
Saucon Valley High School
Shawnee Elementary #1
Siegfried Elementary #1
Stroudsburg Middle School
Stroudsburg High School
Swiftwater Elementary #1
Swiftwater Intermediate #1
Washington Elementary
William Township Elementary
Wilson Intermediate School
Other:
Other Value
Please choose the program associated
Autistic Support Elementary Classroom
Autistic Support Secondary Classroom
Colonial Academy
Early Intervention Program
IBHS
Life Skills Classroom
Multiple Disabilities/Physical Support Classroom
Partial Hospitalization Program
Resolve Therapeutic Emotional Support
Speech/Hearing/Vision
Student Services
Unknown
Other:
Other Value
Nursing Verification
Nursing Certifications Verified
Yes
No
HR Verification
All clearances were verified by Human Resources
Yes
No
Previous
←
Next
→
Enter your save and resume password
Cancel
Confirm