PAL REGISTRATION FORM
2015-2016 School Year
Interested in becoming a PAL, please complete and return the PAL Registration Form along with
providing the following three (3) clearances:
 Act 114 FBI Clearance (date of clearance must be less than one year old)
 Act 34 PA Criminal History Clearance (date of clearance must be less than one year old)
 Act 151 PA Child Abuse Clearance (date of clearance must be less than one year old)
See page 1 for information on how to apply for clearances
Submit the above to:
BRENDA BITZ, PAL VOLUNTEER COORDINATOR
DERRY AREA SCHOOL DISTRICT
982 NORTH CHESTNUT STREET EXTENSION
DERRY PA 15627-7600
724-694-1400 – office
bkbitz@derryasd.k12.pa.us - email
Name
Miss
Ms.
Mrs.
Mr.
Phone:
Address:
Email Address:
Date of Birth (optional)
Day
Month
Pick your best day:
Pick your best time: 9:30 - 11:30 AM
(Teacher Preferred) 
1:00 - 3:00 PM
(School Preferred) 
(Your Child’s Full Name & Grade) 
Please note: After submitting completed PAL Registration form and providing the required
three (3) clearances; Act 114 FBI Clearance (date of clearance must be less than one year old);
Act 34 PA Criminal History Clearance (date of clearance must be less than one year old); and
the Act 151 PA Child Abuse Clearance (date of clearance must be less than one year old),
PAL volunteer will be assigned to a teacher. We will attempt to honor your teacher requests,
but there is no guarantee.
DASD NEW PAL ORIENTATION - 2015-2016
Those who have never volunteered in the Derry Area School District must attend the New PAL
Orientation scheduled for. . . THURSDAY, SEPTEMBER 3, 2015, IN THE ADMINISTRATION BUILDING
BOARD ROOM AT 10:00 AM.
I will attend.
I will not attend.
If you are unable to attend, arrangements will be made to meet with you at another time.
If you have any questions, please call Brenda at 724-694-1400.
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