Please apply ASAP

Enrollment is limited.

The number of credits/hours per courseencompasses both in-class activities and out-of-class assignments.

Name of Applicant – Include
Title: (Ms. Mrs. Mr. Dr. Fr. Sr.)
Name to be Printed on Certificate
Present Position

PIL COURSE SELECTION: (Review courses available in your region at the website listed below, and check the course for which you are applying.)

Check / COHORT / Act 48 PIL Credits
CPE Hours / No. of
Days / PIL
REGION / LOCATION
(first session) / START
DATE
NISL Course 1*
NISL Course 1 is a prerequisite for NISL Courses 2, 3, 4 / 3 Credits
90 Hours / 8
NISL Course 2 / 3 Credits
90 Hours / 8
NISL Course 3 / 1.5 Credits
45 Hours / 4
NISL Course 4* / 2 Credits
60 Hours / 6
NISL- Instructional Coaching Institute / 1 Credit
30 Hours / 3
NISL Leadership in Students with Disabilities / 1 Credit
30 Hours / 3
Early Childhood Executive Leadership Institute (ECEL) / 2 Credits
60 Hours / 5
Effective Communication (Blended Course: Online & 1 Face-to-Face) / 1 Credit
30 Hours / 8 Weeks

* Required for Principal Induction Program

YEARS AS AN ADMINISTRATOR:

(Please indicate the number of years of administrative experience through June 2015.)

POSITION / YEARS / POSITION / YEARS
Assistant Principal / Intermediate Unit Assistant Executive Dir.
Principal / Intermediate Unit Executive Director
Assistant Superintendent / Vocational-Technical School Director
Superintendent / Other (Please list.)
Date Hired in Current Position:
Were you a principal prior to January 1, 2008? If so, where and when.
Are you a new assistant/vice principal or principal who must fulfill the Act 45 Principal Induction Program requirement?

APPLICANT INFORMATION:

Intermediate Unit
County
School District
*District (9-digit) AUN #
No. of Students in District
School
No. of Students in School
List grades you oversee, including pre-school programs.
School Address
City/State/Zip Code
Work Email address
Office Phone/Extension
Office Fax
Home Address
City
State
Zip Code
Home Phone
Cell Phone

*District AUN # --- Go to http://www.edna.ed.state.pa.us/aun_listing.asp

EDUCATION: (Please cite most recent experience first.)

UNIVERSITY/COLLEGE / DEGREE / DATE OBTAINED

PA CERTIFICATES HELD:

CERTIFICATE / DATE ISSUED

PRIOR ADMINISTRATIVE EXPERIENCE:

Title
Dates employed
School District
City, State, Zip Code
Title
Dates Employed
School District
City, State, Zip Code

ACT 48 CREDIT:

PPID Number
What year does your current Act 48 compliance period end?
How many additional Act 48 PIL hours do you need by the end of your compliance period?

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
Supervisor’s Title
Supervisor’s District or School
Office Address
Office Phone/Extension
Office Fax
Email Address

STATEMENTS OF UNDERSTANDING AND AFFIRMATION:

CHECK
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.
I understand that there will be a considerable amount of preparation including prior reading assignments and, in some cases, online work for each unit.
I understand that I will be expected to complete job-embedded activities throughout the course.
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.

Please email, fax, or mail application to the appropriate person in your region

REGION 1 / REGION 2 / REGION 3 / REGION 4
IU -- 22, 23, 24, 25, 26
Lead Site Coordinator
John Romanoski
1144 Wendler Circle
Pottstown, PA. 19465
484 300-5366

Asst. Site Coordinator
Joe Kircher
215-675-4273
/ IU -- 14, 20, 21, 29
Site Coordinator
Dr. Lee Fredericks
73 Fairwood Avenue
Sinking Spring, PA 19608
610-678-2579 (also Fax)
/ IU -- 18, 19
Site Coordinator
Hal Bloss
Northeastern Educational IU 19
1200 Line Street
Archbald, PA 18403-2331
570- 876-9226
570-876-8662 (fax)
/ IU – 9, 16, 17
Site Coordinator
Douglas Ulkins
BLaST IU 17
Region 4 Site Coordinator
294 Wilcox Drive
Troy, PA. 16947
570-506-4089

Send Application To: / Send Application To: / Send Application To: / Send Application To:
Jennifer Lally
Chester County IU 24
455 Boot Road
Downingtown, PA 19335
484-237-5194 (Fax) / Heidi Gamler
Berks County IU 14
1111 Commons Boulevard
P.O. Box 16050
Reading, PA 19612-6050
610-987-8497 (Fax)
/ Kimberly A. Phillips
Northeastern Educational IU 19
1200 Line Street
Archbald, PA 18403-2331
570-876-8662 (Fax)
/ Nancy Regopoulos
BLaST IU 17
2400 Reach Road
P.O. Box 3609
Williamsport, PA 17701
570-323-1738 (Fax)

REGION 5 / REGION 6 / REGION 7 / REGION 8
IU -- 12, 13, 15
Site Coordinator
Dr. Michael C. Young
737 Jake Landis Road
Lititz, PA 17543
717-808-7802
/ IU -- 8, 10, 11
Site Coordinator
Edward Curry
Tuscarora IU 11
2527 US Highway 522 South
McVeytown, PA 17051-9717 717-363-1165
/ IU -- 1, 2, 3, 7, 27
Site Coordinator
Dr. Dean A. Casello
Allegheny IU 3
475 East Waterfront Drive
Homestead, PA 15120
412-394-5752
412-394-5750 (Fax)
/ IU – 4, 5, 6, 28
Site Coordinator
Della Gentile
NW Tri-County IU 5
Della J. Gentile
Region 8 Site Coordinator
8 Market Street
Corry, PA 16407
814-873-8866

Send Application To: / Send Application To: / Send Application To: / Send Application To:
Rebecca Schrecengost
Lancaster-Lebanon IU 13
1020 New Holland Avenue
Lancaster PA 17601
FAX 717-606-1991
/ Kathy Clark
Tuscarora IU 11
2527 US Highway 522 S. McVeytown, PA 17051-9717
814 542 2501 ext. 190
814-542-2569 (Fax)
/ Denise Pilarski
Allegheny IU 3
475 East Waterfront Drive
Homestead, PA 15120
412-394-5750 (Fax)
/ Karen Reagan
NW Tri-County IU 5
252 Waterford Street
Edinboro, PA 16412
814-734-5806 (fax)

All program costs, including tuition, meals, and materials, will be paid by the Pennsylvania Department of Education except for participant travel expenses to the course locations.

This application may be obtained online at:

http://www.education.state.pa.us/portal/server.pt/community/pa_inspired_leaders/8922

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PA Inspired Leadership Program
Application Form March 3, 2015