TherAbilities Application

Name

First Name

Last Name

Desired Position

Degree/s

PA State License Number

License Renewal Date

PA State Driver's License Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Clearances Required

To work in the Pennsylvania public school system, you must have clearances and proof of training/medical testing. Please check your current clearances that do not expire within the year.

Act 34: Child Abuse Clearance

Act 151: Criminal Record Check

Act 114: Federal Criminal History Record

Tuberculosis Testing

Mandated Reporters of Child Abuse and Neglect (Dept of Ed. Approved Course)

Professional Malpractice Insurance

Professional Malpractice Insurance for all employees (minimum limits of $1,000,000 and $3,000,000 aggregate is recommended). If you have your own insurance, please list the Company, Policy Number, limits, and dates below (or attach a copy). If you do not currently have your own insurance, please indicate “no”.

Yes

Essential Job Functions for School Systems Position

Please estimate your present skill levels for the identified essential job functions in school practice using the following abbreviations: –Beginner (have little, if any, work experience with these skills) –Intermediate (have at least two years work experience, but still need on-site support) -Advanced (have many years of work experience; would not need on-site support)

Scheduling school-based student services

Conducting evaluations (standardized & non-standardized)

Providing individualized student treatment and support

Providing group student treatment and support

Providing supports for school personnel

Documenting student’s present levels, student-specific goals, specially designed instruction, and ongoing progress monitoring

Presenting at IEP and/or educational team meetings

Making equipment recommendations to promote student function

Traveling to required school buildings

Please describe briefly what is motivating you to seek out this particular job position:

Please note that if you are offered a position with our practice, we will be asking you to disclose whether you require any accommodations to accomplish the essential functions of the position. A letter confirming a medical condition will be required should any special accommodations be requested. These will be requested within 24 hours following any job offer made to applicants. Any questions about this policy can be directed to Tammy Sarracino, Director, TSarracino@TherAbilities.com or by calling 717.540.9218.