Phone Number
Contract Length
Year of Participation in the Teacher Induction Program
e.g., 2021-2022
Hire Date
Participating Teacher Information
Participating Teacher Assignment While Enrolled in the Teacher Induction Program
Teacher Induction Program | California State University, Fullerton
Continuing Student New Candidate
Number of Students
Subject(s) and Grade level(s) for Each Class Assigned
Total Periods/Hours of Assignment School Name School Website
Applicant: Please have your administrator complete and sign this form and send the completed form to for review.
Administrator: You have received this form because your teacher (listed below) has applied to CSUF’s Teacher Induction
Program. Please verify this participating teachers current teaching assignment, and indicate your approval and
agreement for them to participate in this program below.
More information on these requirements is available online: If you have any
questions about the Teacher Induction Program or this form, please email
29377 03/21
*It is the responsibility of the TIP participating teacher to notify the TIP Coordinator and submit a revised Administrator Agreement form if at any point
the information provided above changes (i.e.; job, assignment, administrator, etc.) while they are participating in the Teacher Induction Program.
Administrator Cooperation and Verification
Please review the following areas where your cooperation is required and sign below to indicate agreement with all items:
I confirm that the participating teacher listed above is/will be employed as the TEACHER OF RECORD for the teaching
assignment above for at least 25% time and teach a minimum of 10 students for the duration of their participation in the
Teacher Induction Program. (Substitute teachers are not eligible for this program.)
I agree to update the Teacher Induction Coordinator of any changes in the employment status of the
participating teacher.
I agree to select and identify a mentor (below) for the participating teacher based on CTC and TIP criteria, as well as
district/agency procedures and policies. (This will be done via our Mentor Agreement form.)
I will ensure that the mentor selected will be provided sucient time to fulfill mentor responsibilities (per CTC
requirements, approximately one hour per week for the 12-week CSUF semesters).
Mentor Name
Administrator Name Administrator Email
Mentor Email
Administrator Signature
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