Form: Counselor Supervisor Info and Payment Form Fall 2012

Owner: The Sage Colleges Education <sageadmin>
Owner's Email: SoELTAdmin@sage.edu
Dataset: Counselor Supervisor Info and Payment Form Fall 12
EDIT: Y, VIEW: N, REQR: N
1
Thank you for completing this form. We will be asking you every three years to update this information while you remain a cooperating teacher. None of the information is sold; all information is used solely for the purpose of School of Education.
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2
Today's Date
 (MM/DD/YYYY)
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3
Your First Name
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4
Your Last Name
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5
Ethnicity
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6
Tax Address Street/ PO Box
Used to mail stipend or certificate
Please let us know if this should change (518-244-2326).
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7
Home Address City/ Town
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8
Home Address State
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Home Address Zip Code
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10
Home phone number
Used ONLY if necessary regarding "Thank You" option.
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11
Email address
List address you use year round. Your email is kept within SoE and not shared with outside businesses.
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12
Your "Thank You" option for 600 hours.
Please check only one item.
$300: If you choose the $300 stipend, your Social Security number or Tax ID number and electronic signature is required below.
m.o.s.s. bookstore $300 gift card
3 credit course voucher: The 3 credit course voucher can be used at any of The Sage Colleges WITHIN ONE YEAR of the issue date. The waiver may only be issued to you or a colleague in your district.
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13
Social Security number
Only office staff will have access to this form and your number. If you are uncomfortable listing it, you can call (518) 244-2326 to provide the number to School of Education administrative assistant.
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14
Please check this box to indicate this is your electronic signature needed for the $300 stipend.
If checked this is considered my electronic signature.
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15
Name of "other" to receive 3 credit course waiver and this person's relationship to you.
Complete this if you are choosing the course waiver and want to provide it to dependent family member or spouse.
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16
School District Name
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School Building Name
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School Address Street / PO Box
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School Address City/ Town
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School Address Zip Code
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21
School Phone Number
Include area code
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22
The following information is needed for our accreditation. We must provide data to illustrate our cooperating counselors are qualified through their education and years of counseling.
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23
Current level as counselor
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24
Please indicate the number of years you have counseled at particular levels. Answer ONLY those areas that pertain to you.
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25
Elementary Grades
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Middle School (5th-8th/9th grades)
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Junior High School (7th-8th/9th grades)
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High School (9th-12th grades)
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For the items below, what is your institutional preparation?
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Undergraduate Institution
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Undergrad Major and Degree
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Graduate Institution(s)
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Grad Degree(s)
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Certifications you have from NYS
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Certifications from other states
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36
Please list all current memberships, positions, and offices in professional associations at the local, state, and national levels.
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37
THANK YOU for being our partner in Education!