04.2019
AACS Continuing Education
Supervising Teacher
(Mentor of Student Teacher or Mentor in Approved Program)
Directions:
• Print legibly.
• This form is required to verify that the supervising teacher mentored a student in an approved mentoring program or
supervised a student teacher for a full-time student teaching experience. (Typically, the student teacher receives 9 to 12 college
credits for this course.)
• School administrator’s signature is required. In lieu of the school administrator’s signature, the supervising teacher can submit
documentation from the college that assigned the credit to the student teacher.
• Retain this form. When you submit certification renewal application, include this form (and college documentation, if
applicable) with your other renewal paperwork.
• For certificate renewal, no more than 10 contact hours may be for supervising a student teacher or mentoring in an approved
mentoring program.
• Supervising/mentoring is valued at 10 contact hours.
Supervising Teacher Information
Name E-mail
Certification Area
Preschool
Kindergarten
Elementary
Secondary
All-Level (Music, Art, PE)
Special Education
Specialist (Bible, CIT, Counseling)
Administrator
Current Certificate Endorsement(s) (Elementary Ed, Music, Math, etc.)
Information for Student Teacher
Name of Student Teacher ________________________________________________________________________________________
College (That Awarded the Student Teacher Credit for Student Teaching) _________________________________________________
College Address (City, State) ______________________________________________________________________________________
Dates of Student Teaching_________________________________ Credits Awarded _______________________________________
Teachers for Tomorrow Mentoring Program
Verifier’s Information
Name of School Administrator or College Program Director _____________________________________________________________
Signature* ______________________________________________ Date ________________________________________________
* Signature verifies the supervising teacher’s participation.
For Office Use Only
Continuing education credit granted
Continuing education credit denied Explanation of denial:
Number of contact hours allowed for activity: _______
Conditions or limitations:
Signature of AACS official Date of Reply_____________________
