Immunization /.

Injection Details

Page 1 of 2

PPD
Vaccination Given in Past N 0 Y
Visit date

2015-03-24 F/U

Dose

units

Status

Dose Number

Administered

Reason

r--

Lot Number jC4582AA

Location

Given By * rivielo,Roldan

D VFC

Given
Date/Time *

Right Lower Forearm

Route Intradermal

Manufacturer

Exp. Date [11/04/2016

VFC

VIS Given
[R] 03/24/2015
Date
Induration

itiA:444g5

14
-

'. .. 2,

[03:31 PM

Date on VIS
Read by

Impression [Negative

Read Date

Comments i Kallie Edge PPD was read on

1 3/26/15 was Negative.

5 03/26/2015
Decrement the dose
Billable
17.,7._
1 Counseling

, Cancel

https://asp25.medalliesasp.com:1005.3/mobilecloc/jspkatalog/ImmunizationDetail.jsp?TrU...
abed

3/27/2015

0098Z9L171.6 WIDAH WV9041. gLOZ

Z.? ,e

DIVISION OF HUMAN RESOURCES HR CONNECT WALK-IN CENTER

65 Court Street, Brooklyn, New York 11201 Room # 102 718-935-4000

Depanraent of
Eaturgation
a-matutftr

7:*$rteg3-

Applicants Social Security #

Last Name:

0
First:

L1

E
tAkDOE
YC FINGERPRINTING-CENTRAL ($115 FEE) n NYCDOE FINGERPRINTING-FIELD ($135 FEE)

NYSED FINGERPRINTING ($10

REPRINT (No Fee)

OPSRA 104 (NO FEE)

OSPRA 103 (NO FEE)

($60 FEE)

Representative

Date:

** INGERP

F P ABLE TO: NYCDOE/DMIT **

THIS IS NOT A
CE E E' THIS A ONLY A RECEIPT. PLEASE BE AD USED THAT LIMY!:
YOU RECEIVE FURTHER NOTICE FROM THE NYCDOE, YOU ARE NOT CLEARED TO WORK

NYC bEtiO-k)1 I:, Al iON

174-

65 .C.CART 5Th

12:0124
. 04197

0811612013
!K097=6613

CREDIT CARD
tJlr

0008
000223
536258
Swiped
Online

$115.00
F..R COPY

Page 1 of 2
Lehman Graduate Record for Advisor Use Only

Kahle Edge
Name:
Student ID: 23116352

Course
Contact Hours:
Course Attributes:
Instructor:
EDG 707
Contact Hours:
Course Attributes:
Instructor:

Student Address: 63 Elmore Avenue

Croton on Hudson, NY 10520-2718
09/10/2015
Print Date:

Beginning of Graduate Record

2012 FA

Earn Grd

Description
3.00
Evening Class
Elliot Resnick
Practicum-Counseling
3.00
Evening Class
Stuart Chen-hayes
1.850

Term GPA:

Term Total:

0.00 WU

Attempt
6.00

Earn
3.00

Health Pre-K-12 Major

Course
EDG 700
Contact Hours:
Course Attributes:
Instructor:
EDG 701
Contact Hours:
Course Attributes:
Instructor:

Term GPA:

Subplan:
Course
EDG 702
Contact Hours:
Course Attributes:
Instructor:
EDG 705
Contact Hours:
Course Attributes:
Instructor:

Earn Crrd
3.00 B

Description
Prof.Ident.Incounsel
3.00
Evening Class
Stuart Chen-hayes
Counsel.Theor&Technq
3.00
Evening Class
William Cipriano
3.150

Term Total:

2014 FA

Counselor Education Major

Guidance & Counseling Specialization

Subplan:
3.00 B+

Attempt
6.00

Course
EDG 709
Contact Hours:
Course Attributes:
Instructor:

Earn
6.00

Term GPA:

2015 SP

Counselor Education Major

Guidance & Counseling Specialization

Subplan:
Earn Grd
3.00 A-

3.500

Term Total:

3.00 B+

Attempt
6.00

Course
EDG 707
Contact Hours:
Course Attributes:
Instructor:
EDG 732
Contact Hours:
Course Attributes:
Instructor:

Earn
6.00

Description
Human Dev.In Counsel
3.00
Evening Class
Marie McCormick
Career Counseling
3.00
Evening Class
Tamisha Bouknight

Term GPA:

2.850

Term Total:

Course
EDG 735
Contact Hours:
Course Attributes:
Instructor:

Attempt
6.00

Course

E Grd
3.00 A-

Earn Grd
3.00 B

3.00 A

Attempt
6.00

6.00

3.300

Term Total:

Earn Grd
3.00 B+

Attempt
3.00

Bann
3.00

2015 FA

Earn
6.00

Counselor Education Major

Guidance & Counseling Specialization
Description
Assess.ln Counseling

Description
Family Counseling
3.00
Day Class
William Cipriano

Term GPA:

2014 SP

Course
EDG 706

Term Total:

3.00 B

Subplan:

Subplan:

3.500

Earn
3.00

2015 SU
Counselor Education Major
Guidance & Counseling Specialization

Subplan:
Earn Grd
3.00 B-

Attempt
3.00

Description
Practicum-Counseling
3.00
Evening Class
Queenette Nwobodo
Abuse,Viol/Che Depen
3.00
Evening Class
Suzette Ramsundar

Term GPA:

2013 FA

Counselor Education Major

Guidance & Counseling Specialization

Course
EDG 703
Contact Hours:
Course Attributes:
Instructor:
EDG 704
Contact Hours:
Course Attributes:
Instructor:

Term Total:

2013 SP

Term GPA:

Subplan:

3.000

Counselor Education Major

Guidance & Counseling Specialization
Description
Multicult.Counseling
3.00
Evening Class
Faith Deveaux
Group Counseling
3.00
Evening Class
William Cipriano

Earn Crrd
3.00 B

Description
Ldrshp Adv Chng Sell(
3.00
Evening Class
Tamisha Bouknight

EDG 708
Contact Hours:
Course Attributes:
Instructor:
EDG 733

Counselor Education Major

Guidance & Counseling Specialization
Description
Couns Rsrch Eval I
3.00
Evening Class
Tamisha Bouknight
Devpmt School Couns

Lam ad
0.00

0.00

O 0 AMERICAN
"...4% SCHOOL
11 COUNSELOR

00

Ipg ASSOCIATION

1101 King Street, Suite 310

Alexandria, VA 22314
703-683-2722
703-997-7572

Print Member Cod I

1
#..m..6%.6

AMERICAN
SCHOOL

111I1

ASSOCIATION

COUNSELOR

Name:
Member ID:
Username:

Mrs. Kallie Edge

147673
Kallie

Expiration Date:

3/17/2016

TIE - EDUCATORS PROFESSIONAL LIABILITY

B.

Educators Employment Liability Acts or Omissions Limit of Liability:

$ 1,000,000 per Insured for each Educators Employment Liability Act or Omission
$ 1,000,000 Aggregate per Insured for all Educators Employment Liability Acts or Omissions
( see Item 4. F. for sublimit regarding Claims we elect to defend )

C.

Bail Bond Coverage Limit:

D.

$ 10,000 Per Claim, Per Policy Period

$ 1,000 Per Bail Bond, Per Policy Period

E.

Sexual Misconduct Defense Coverage

Limit:
$ 35,000 Per Claim, Per Policy Period
$ 35.000 Aggregate, Per Policy Period

Corporal Punishment Defense Coverage Limit:

F.

Educators Employment Liability Act or

Omission Defense Limit:
$ 5,000 Per Insured for each Educators
Employment Liability Act or Omission
$ 5,000 Aggregate, per Policy Period

The following forms and endorsements are made a part of and attached to this policy at inception:

09011L0903, 4382PL0805, 4394PL0804, 4395PL0804, 4397PL0804, 4223PL0104, 4289PL0104,

41691L1004, 4459PL1004, Privacy Notice, State Mandatory Endorsements

43 90 PL 08 04

Page 2 of 2

TIE - EDUCATORS PROFESSIONAL LIABILITY

INSURER:

SAVERS
PROPERTY

Savers Property & Casualty

Insurance Co. ( A stock company )
11880 College Blvd. - Suite 500
Overland Park, KS 66210

INSURANCE

COMPANY
.4 member

( 800) 351 -1411

Memiatebrovk

In consideration of the payment of premium when due, it is agreed and understood that, solely with respect
to the Insured(s) set forth in Item #1 of this Declarations, the EDUCATORS PROFESSIONAL LIABILITY
POLICY on Form 4382 PL applies as specified. It is further agreed and understood the coverage is applicable
to Members shown in the Master Membership List of Insured Members maintained by the Association.

TIE IN-DUES BASIC

MEMBER DECLARATIONS PAGE
EDUCATORS PROFESSIONAL LIABILITY POLICY
Policy Number: GL0000011
Renewal of:

GL0000011

ITEM 1. NAMED INSURED

Each Member shown in the Master Membership List of Insured Members maintained by the
Association.
ITEM 2.

POLICY PERIOD

The policy period indicated in the Master Membership List of Insured Members that is associated with
each individual Insured Member.
ITEM 3. ASSOCIATION: ASCA
A voting member of the Trust for Insuring Educators and participant in the Trust's Educators Professional
Liability Programs.
Producer's Name & Address:

David J. Smith, Agent / Broker

c/o FORREST T. JONES & COMPANY, INC.
P.O. Box 418131
Kansas City, MO 64141-9131
Phone: (800) 821-7303

ITEM 4. LIMITS OF LIABILITY

A. Educators Professional Liability Acts or Omissions Limit of Liability:
$ 1, 000,000 per Insured for each Educators Professional Liability Act or Omission
$ 1.000,000 Aggregate per Insured for all Educators Professional Liability Acts or Omissions

43 90 PL 08 04

Page 1 of 2

COUNSELOR EDUCATION/SCHOOL COUNSELING PRACTICUM AND INTERNSHIP

HANDBOOK RECEIPT - STUDENT
As part of your Practicum/Internship application, it is your responsibility to read the Practicum and
Internship Handbook and to provide a copy for your on-site supervisor.
Please sign below to indicate your receipt of the School Counseling Practicum and Internship Handbook.
Return this along with the signed receipt from your site supervisor as part of your Practicum/Internship
application packet. Thank you.
Practicum/Internship Semester:
Student Name (Please print):
STUDENT SIGNATURE:
DATE:

I 2z15

Fall

KW I it E(2i96

/Yr:

2015

COUNSELOR EDUCATION/SCHOOL COUNSELING PRACTICUM AND INTERNSHIP

HANDBOOK RECEIPT - STUDENT
As part of your Practicum/Internship application, it is your responsibility to read the Practicum and
Internship Handbook and to provide a copy for your on-site supervisor.
Please sign below to indicate your receipt of the School Counseling Practicum and Internship Handbook.
Return this along with the signed receipt from your site supervisor as part of your Practicum/Internship
application packet. Thank you.
Practicum/Internship Semester:
Student Name (Please print):
STUDENT SIGNATURE:
DATE:

I 2z15

Fall

KW I it E(2i96

/Yr:

2015

TIE - EDUCATORS PROFESSIONAL LIABILITY

INSURER:

SAVERS
PROPERTY

Savers Property & Casualty

Insurance Co. ( A stock company )
11880 College Blvd. - Suite 500
Overland Park, KS 66210

INSURANCE

COMPANY
.4 member

( 800) 351 -1411

Memiatebrovk

In consideration of the payment of premium when due, it is agreed and understood that, solely with respect
to the Insured(s) set forth in Item #1 of this Declarations, the EDUCATORS PROFESSIONAL LIABILITY
POLICY on Form 4382 PL applies as specified. It is further agreed and understood the coverage is applicable
to Members shown in the Master Membership List of Insured Members maintained by the Association.

TIE IN-DUES BASIC

MEMBER DECLARATIONS PAGE
EDUCATORS PROFESSIONAL LIABILITY POLICY
Policy Number: GL0000011
Renewal of:

GL0000011

ITEM 1. NAMED INSURED

Each Member shown in the Master Membership List of Insured Members maintained by the
Association.
ITEM 2.

POLICY PERIOD

The policy period indicated in the Master Membership List of Insured Members that is associated with
each individual Insured Member.
ITEM 3. ASSOCIATION: ASCA
A voting member of the Trust for Insuring Educators and participant in the Trust's Educators Professional
Liability Programs.
Producer's Name & Address:

David J. Smith, Agent / Broker

c/o FORREST T. JONES & COMPANY, INC.
P.O. Box 418131
Kansas City, MO 64141-9131
Phone: (800) 821-7303

ITEM 4. LIMITS OF LIABILITY

A. Educators Professional Liability Acts or Omissions Limit of Liability:
$ 1, 000,000 per Insured for each Educators Professional Liability Act or Omission
$ 1.000,000 Aggregate per Insured for all Educators Professional Liability Acts or Omissions

43 90 PL 08 04

Page 1 of 2

TIE - EDUCATORS PROFESSIONAL LIABILITY

B.

Educators Employment Liability Acts or Omissions Limit of Liability:

$ 1,000,000 per Insured for each Educators Employment Liability Act or Omission
$ 1,000,000 Aggregate per Insured for all Educators Employment Liability Acts or Omissions
( see Item 4. F. for sublimit regarding Claims we elect to defend )

C.

Bail Bond Coverage Limit:

D.

$ 10,000 Per Claim, Per Policy Period

$ 1,000 Per Bail Bond, Per Policy Period

E.

Sexual Misconduct Defense Coverage

Limit:
$ 35,000 Per Claim, Per Policy Period
$ 35.000 Aggregate, Per Policy Period

Corporal Punishment Defense Coverage Limit:

F.

Educators Employment Liability Act or

Omission Defense Limit:
$ 5,000 Per Insured for each Educators
Employment Liability Act or Omission
$ 5,000 Aggregate, per Policy Period

The following forms and endorsements are made a part of and attached to this policy at inception:

09011L0903, 4382PL0805, 4394PL0804, 4395PL0804, 4397PL0804, 4223PL0104, 4289PL0104,

41691L1004, 4459PL1004, Privacy Notice, State Mandatory Endorsements

43 90 PL 08 04

Page 2 of 2

O 0 AMERICAN
"...4% SCHOOL
11 COUNSELOR

00

Ipg ASSOCIATION

1101 King Street, Suite 310

Alexandria, VA 22314
703-683-2722
703-997-7572

Print Member Cod I

1
#..m..6%.6

AMERICAN
SCHOOL

111I1

ASSOCIATION

COUNSELOR

Name:
Member ID:
Username:

Mrs. Kallie Edge

147673
Kallie

Expiration Date:

3/17/2016

Page 1 of 2
Lehman Graduate Record for Advisor Use Only

Kahle Edge
Name:
Student ID: 23116352

Course
Contact Hours:
Course Attributes:
Instructor:
EDG 707
Contact Hours:
Course Attributes:
Instructor:

Student Address: 63 Elmore Avenue

Croton on Hudson, NY 10520-2718
09/10/2015
Print Date:

Beginning of Graduate Record

2012 FA

Earn Grd

Description
3.00
Evening Class
Elliot Resnick
Practicum-Counseling
3.00
Evening Class
Stuart Chen-hayes
1.850

Term GPA:

Term Total:

0.00 WU

Attempt
6.00

Earn
3.00

Health Pre-K-12 Major

Course
EDG 700
Contact Hours:
Course Attributes:
Instructor:
EDG 701
Contact Hours:
Course Attributes:
Instructor:

Term GPA:

Subplan:
Course
EDG 702
Contact Hours:
Course Attributes:
Instructor:
EDG 705
Contact Hours:
Course Attributes:
Instructor:

Earn Crrd
3.00 B

Description
Prof.Ident.Incounsel
3.00
Evening Class
Stuart Chen-hayes
Counsel.Theor&Technq
3.00
Evening Class
William Cipriano
3.150

Term Total:

2014 FA

Counselor Education Major

Guidance & Counseling Specialization

Subplan:
3.00 B+

Attempt
6.00

Course
EDG 709
Contact Hours:
Course Attributes:
Instructor:

Earn
6.00

Term GPA:

2015 SP

Counselor Education Major

Guidance & Counseling Specialization

Subplan:
Earn Grd
3.00 A-

3.500

Term Total:

3.00 B+

Attempt
6.00

Course
EDG 707
Contact Hours:
Course Attributes:
Instructor:
EDG 732
Contact Hours:
Course Attributes:
Instructor:

Earn
6.00

Description
Human Dev.In Counsel
3.00
Evening Class
Marie McCormick
Career Counseling
3.00
Evening Class
Tamisha Bouknight

Term GPA:

2.850

Term Total:

Course
EDG 735
Contact Hours:
Course Attributes:
Instructor:

Attempt
6.00

Course

E Grd
3.00 A-

Earn Grd
3.00 B

3.00 A

Attempt
6.00

6.00

3.300

Term Total:

Earn Grd
3.00 B+

Attempt
3.00

Bann
3.00

2015 FA

Earn
6.00

Counselor Education Major

Guidance & Counseling Specialization
Description
Assess.ln Counseling

Description
Family Counseling
3.00
Day Class
William Cipriano

Term GPA:

2014 SP

Course
EDG 706

Term Total:

3.00 B

Subplan:

Subplan:

3.500

Earn
3.00

2015 SU
Counselor Education Major
Guidance & Counseling Specialization

Subplan:
Earn Grd
3.00 B-

Attempt
3.00

Description
Practicum-Counseling
3.00
Evening Class
Queenette Nwobodo
Abuse,Viol/Che Depen
3.00
Evening Class
Suzette Ramsundar

Term GPA:

2013 FA

Counselor Education Major

Guidance & Counseling Specialization

Course
EDG 703
Contact Hours:
Course Attributes:
Instructor:
EDG 704
Contact Hours:
Course Attributes:
Instructor:

Term Total:

2013 SP

Term GPA:

Subplan:

3.000

Counselor Education Major

Guidance & Counseling Specialization
Description
Multicult.Counseling
3.00
Evening Class
Faith Deveaux
Group Counseling
3.00
Evening Class
William Cipriano

Earn Crrd
3.00 B

Description
Ldrshp Adv Chng Sell(
3.00
Evening Class
Tamisha Bouknight

EDG 708
Contact Hours:
Course Attributes:
Instructor:
EDG 733

Counselor Education Major

Guidance & Counseling Specialization
Description
Couns Rsrch Eval I
3.00
Evening Class
Tamisha Bouknight
Devpmt School Couns

Lam ad
0.00

0.00

DIVISION OF HUMAN RESOURCES HR CONNECT WALK-IN CENTER

65 Court Street, Brooklyn, New York 11201 Room # 102 718-935-4000

Depanraent of
Eaturgation
a-matutftr

7:*$rteg3-

Applicants Social Security #

Last Name:

0
First:

L1

E
tAkDOE
YC FINGERPRINTING-CENTRAL ($115 FEE) n NYCDOE FINGERPRINTING-FIELD ($135 FEE)

NYSED FINGERPRINTING ($10

REPRINT (No Fee)

OPSRA 104 (NO FEE)

OSPRA 103 (NO FEE)

($60 FEE)

Representative

Date:

** INGERP

F P ABLE TO: NYCDOE/DMIT **

THIS IS NOT A
CE E E' THIS A ONLY A RECEIPT. PLEASE BE AD USED THAT LIMY!:
YOU RECEIVE FURTHER NOTICE FROM THE NYCDOE, YOU ARE NOT CLEARED TO WORK

NYC bEtiO-k)1 I:, Al iON

174-

65 .C.CART 5Th

12:0124
. 04197

0811612013
!K097=6613

CREDIT CARD
tJlr

0008
000223
536258
Swiped
Online

$115.00
F..R COPY

Immunization /.Injection Details

Page 1 of 2

PPD
Vaccination Given in Past N 0 Y
Visit date

2015-03-24 F/U

Dose

units

Status

Dose Number

Administered

Reason

r--

Lot Number jC4582AA

Location

Given By * rivielo,Roldan

D VFC

Given
Date/Time *

Right Lower Forearm

Route Intradermal

Manufacturer

Exp. Date [11/04/2016

VFC

VIS Given
[R] 03/24/2015
Date
Induration

itiA:444g5

14
-

'. .. 2,

[03:31 PM

Date on VIS
Read by

Impression [Negative

Read Date

Comments i Kallie Edge PPD was read on

1 3/26/15 was Negative.

5 03/26/2015
Decrement the dose
Billable
17.,7._
1 Counseling

, Cancel

https://asp25.medalliesasp.com:1005.3/mobilecloc/jspkatalog/ImmunizationDetail.jsp?TrU...
abed

3/27/2015

0098Z9L171.6 WIDAH WV9041. gLOZ

Z.? ,e