Make a Difference, Be a Mentor
Qualifications
• Must hold a Master's Degree.
• Have at least three years experience in the
mentor's current position.
• Be commited to the candidate's successful
completion of degree objectives.
Responsibilities
• Assists candidate as-needed to complete site-
based activities (i.e. facilitating access to school
sites, archives and personnel as needed).
• Facilitates communication with student and
university supervisor for capstone objectives.
• Evaluates candidate's internship experience
and program portfolio upon capstone
completion.
• Maintains communication with university
personnel and candidate as-needed.
What's Next
• Complete and submit the form to the right.
• Please forward specific questions regarding the
mentor program to the chairman of the
Department of Educational Leadership,
Curriculum and Special Education.
• Prepare to mentor and watch the candidate
evolve.
Applicant
Applicant's Name:*
Applicant's ID Number:
Applicant's Intended Program: *
Applicant's Date of Birth:*
(mm/dd/yyyy)
Applicant's Email Address:*
Mentor
Mentor's Name:*
Mentor's Current Position:*
Number of years in current position:*
Acceptable Mentors List
Mentor's School and District:*
Number of Years of Building-Level
Administrative Experience:*
Number of Years of District-Level
Administrative Experience:*
Number of Years of Teaching Experience:*
Highest Degree of the Mentor:*
Are you certified in the following areas?:
In the Applicants Intended Field of Study?*
As a Building-Level Administrator?*
As a District-Level Administrator?*
In Special Education?*
In Gifted/Talented Education?*
In Curriculum?*
Mentor's Email Address:*
Statement of Agreement
I,
agree to mentor
throughout the duration of the on-line degree
program.
By submitting this form, I am agreeing that I meet
all of the qualifications and agree to the
responsibilities described by the Mentor Program.
Thank you,
Office of A-State Online Services
Please complete this form, then print
and fax to:
870-972-3548.
*Mentor Form must be hand signed before
returning*:
Signature:
Applicant's State:*
