Please apply ASAP
Enrollment is limited.The number of credits/hours per course encompasses 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
COHORT:
(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 REGION PIL (first session) LOCATION 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 30 Hours 1 Credit 3
Early Childhood Executive
Leadership Institute (ECEL) 2 Credits 60 Hours 5
* Required for Principal Induction Program
YEARS AS AN ADMINISTRATOR:
(Please indicate the number of years of administrative experience through June 2013.)
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.
APPLICANT INFORMATION:
Intermediate Unit County
School District
*District (9-digit) AUN #
PENNSYLVANIA INSPIRED LEADERSHIP PROGRAM
“Creating Inspired Leaders at All Levels”
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 Office Phone/Extension Office Fax Home Address City State Zip Code Home Phone Cell Phone Email address
*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:
TitleDates employed School District City, State, Zip Code Title
Dates Employed School District City, State, Zip Code
ACT 48 CREDIT:
PPID NumberSUPERVISOR INFORMATION:
Name Supervisor’s Title Supervisor’s District or School Office Address Office Phone/Extension Office Fax Email AddressSTATEMENTS OF UNDERSTANDING AND AFFIRMATION:
CHECKI understand thatin 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 IU -- 14, 20, 21, 29 Site Coordinator
Dr. Lee Fredericks
73 Fairwood Avenue Sinking Spring, PA 19608 610-678-2579 (also Fax) leefre@berksiu.org IU -- 18, 19 Site CoordinatorHal Bloss
Northeastern Educational IU 19 1200 Line Street Archbald, PA 18403-2331 570- 876-9226 570-876-8662 (fax) hbloss@iu19.org IU – 9, 16, 17Site Coordinator
Douglas Ulkins
BLaST IU 17Region 4 Site Coordinator 294 Wilcox Drive
Troy, PA. 16947 570-506-4089 dulkins@IU17.org
Send Application To: Send Application To: Send Application To: Send Application To:
Paula Solomon
Chester County IU 24 455 Boot Road Downingtown, PA 19335 484-237-5194 (Fax) paulas@cciu.orgHeidi Gamler
Berks County IU 14 1111 Commons Boulevard P.O. Box 16050 Reading, PA 19612-6050 610-987-8497 (Fax) heigam@berksiu.orgKimberly A. Phillips
Northeastern Educational IU 19 1200 Line Street Archbald, PA 18403-2331 570-876-8662 (Fax) kphillips@iu19.orgMarlene Ryder
BLaST IU 17 2400 Reach Road P.O. Box 3609 Williamsport, PA 17701 570- 323-1738 (Fax) mryder@iu17.orgREGION 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 mcyoungeducation@gmai l.com IU -- 8, 10, 11 Site Coordinator
Edward Curry
Tuscarora IU 11 2527 US Highway 522 South McVeytown, PA 17051-9717 717-363-1165 ecurry1@live.com IU -- 1, 2, 3, 7, 27 Site CoordinatorDr. Dean A. Casello
Allegheny IU 3475 East Waterfront Drive Homestead, PA 15120 412-394-5752 412-394-5750 (Fax) dean.casello@aiu3.net IU – 4, 5, 6, 28 Site Coordinator
Della Gentile
NW Tri-County IU 5 Della J. GentileRegion 8 Site Coordinator 8 Market Street
Corry, PA 16407 814-873-8866 PILRegion8@iu5.org
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 717-606-1991Kathy Clark
Tuscarora IU 11 2527 US Highway 522 S. McVeytown, PA 17051-9717 814 542 2501 ext. 190 814-542-2569 (Fax)Shelley Hilton
Allegheny IU 3475 East Waterfront Drive Homestead, PA 15120 412-394-5750 (Fax) shelley.hilton@aiu3.net
Karen Reagan
NW Tri-County IU 5
252 Waterford Street Edinboro, PA 16412 814-734-5806 (fax) Karen_reagan@iu5.orgAll 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:
