MO 500-2517 (Rev 06/18)
Please return completed form to:
Missouri Department of Elementary and Secondary Education
Coordinator of Career Education
P.O. Box 480, Jefferson City, Missouri 65102-0480
Questions: Contact Office of College and Career Readiness 573-751-3500
APPLICANT INFORMATION (to be completed by applicant)
LAST NAME
FIRST NAME
MIDDLE INITIAL
COUNTY-DISTRICT CODE
HOME STREET ADDRESS
CELL PHONE
HOME PHONE
CITY
STATE
ZIP CODE
APPLICANT’S SCHOOL EMAIL ADDRESS
APPLICANT’S HOME EMAIL ADDRESS
SCHOOL DISTRICT NAME
SCHOOL BUILDING NAME
TEACHING ASSIGNMENT FOR THE UPCOMING SCHOOL YEAR
Agricultural Education Family and Consumer Sciences Technology and Engineering Education
Business Education Health Sciences Education Counselor 9-12
Cooperative Education Marketing Education Counselor K-12
Occupational Family and Consumer Sciences (specify program area) __________________________________________________________
Skilled Technical Sciences (specify program area) __________________________________________________________________________
STUDENT ORGANIZATION ASSIGNMENTS FOR
THE UPCOMING SCHOOL YEAR
SPECIFY COURSES TO BE TAUGHT
Experienced educator teaching in a program area for the first time
Returning educator teaching in a new program area after absence of five years or more
By signing this application, I commit to actively participate in the mentoring program by communicating regularly with my mentor and attending
all required meetings.
SIGNATURE OF APPLICANT
DATE
SCHOOL DISTRICT COMMITMENT
The school district will provide support for this applicant to participate as a protégé in the Career Education Mentoring Program. This includes
allowing the applicant to: be absent from school for all required meetings and to communicate regularly with the mentor. Upon successful
completion of the program, a stipend of $200 will be paid to the protégé's school. The protégé's expenses related to the mentoring program will be
reimbursed upon the district's discretion.
NAME OF ADMINISTRATOR MAKING COMMITMENT (Please print)
TITLE
SIGNATURE OF ADMINISTRATOR
DATE
The Department of Elementary and Secondary Education does not discriminate on the basis of race, color, religion, gender, national origin, age, or disability in its programs and activities. Inquiries
related to Department programs and to the location of services, activities, and facilities that are accessible by persons with disabilities may be directed to the Jefferson State Office Building, Office
of the General Counsel, Coordinator – Civil Rights Compliance (Title VI/Title IX/504/ADA/Age Act), 6th Floor, 205 Jefferson Street, P.O. Box 480, Jefferson City, MO 65102-0480; telephone number
573-526-4757 or TTY 800-735-2966; email civilrights@dese.mo.gov .
MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION
DIVISION OF LEARNING SERVICES – OFFICE OF COLLEGE AND CAREER READINESS
PROTÉGÉ APPLICATION FOR PARTICIPATION IN CAREER EDUCATION
MENTORING PROGRAM
