11 I understand that I will be eligible for Pennsylvania teaching certification upon successful completion of the program and upon passing the appropriate certification exams, as long as I am a citizen of the United States of America or legally authorized to work in the US. If I choose to pursue certification in another state, it is my responsibility to determine what credentials are needed. I understand that upon graduation I must apply for teaching certification within a reasonable amount of time. If I decide to apply after five (5) years have passed, I must contact the Chief Certification Officer at Lycoming with up-to-date clearances and a professional reference regarding moral character in order for Lycoming to approve my application. I understand that Lycoming College’s general liability insurance extends to experimental learning environments, but I understand that it does not provide legal and/or financial assistance for acts of personal negligence. I understand off-campus field experiences have the potential to present risks beyond campus-based classroom experiences. I am responsible for understanding guidelines and expectations from the College and field experience location. If a concern arises, I must notify my field placement teacher and my campus professor. Possible risks include but are not limited to travel to and from field experiences in your car, public transportation, and on foot; school-safety risks; personal harassment in the form of sexual, ethnic, racial, age, religious, or disability, which are illegal. Please check the appropriate box that pertains to your status: By checking this box, I certify that I have no current or pending record of criminal activity. By checking this box, I am alerting the Education Department that I have a current or pending record of criminal activity. I will arrange a meeting with them to determine the best way to move forward. Please complete the information below to update our records When do you plan to graduate? Semester: Year: What is your major? What is your Certification Program? When do you plan to student teach? Semester: Year: By signing below, you indicate that you have carefully read and fully understand each of the statements. Student’s Name: Student’s Signature: Date:
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