Tolland Public Schools

TOLLAND PUBLIC SCHOOLS

Student Teacher/Observer Form

We are happy to have your participation in the education of Tolland Public School students and are thankful for your gift of time and talent. Please complete the following form and submit it to Kathryn Eidson at Tolland High School, Room 103. We have interoffice mail envelopes in the front office or you can deliver it personally. We need this form in order for you to continue your presence in the school.

Name: ______Tolland School: BGP TIS TMS THS

Date of Birth: ______Social Security Number:______

E-mail Address: ______

Address (residence): (P.O. Box not acceptable) ______

Telephone (home):______(work):______(cell):______

Emergency Contact: ______Phone Number: ______

Dates of Internship: Beginning ______and Ending ______

Internship with (teacher’s name) ______

University Contact: ______Phone Number: ______

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The State of Connecticut’s Department of Education has mandated that you be fingerprinted at a Regional Educational Service Center (RESC) within one year of your placement. Tolland participates with EASTCONN.

Please let us know by checking below where and when you have been fingerprinted.

______I have been fingerprinted at EASTCONN on ______.

______I have been fingerprinted at another RESC* on ______

*If you have been fingerprinted by another RESC, then you must contact Suzanne Waterhouse, HR Generalist, at 860-870-6850 and complete the paperwork in order for the results to be obtained.

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By signing below, I hereby voluntarily authorize the Tolland Public Schools, its agents, officers and employees, to conduct a background check to determine whether I have any criminal convictions on record.

I understand that my participation with the Tolland Public Schools is contingent on the successful completion of this background check. I release the Tolland Public Schools and its representatives and the providers of such information from any and all liability for damage of whatever kind which may at any time result to me, my heirs or assigns, because of compliance with this authorization, the conduct of this background check and release of information or any attempt to comply with it.

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Print Name (Must be done by hand) Date

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Signature (Must be done by hand)

C:\Users\rgavin\Downloads\Volunteer Observer student teacher intern FormUpdated 10-15-12 (1).docx

September, 2010