Mentor Application

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Each interested individual must apply through the form provided. A selection committee will select mentors based on the application information.

The mentor application process is ongoing. Please refer to the schedule for class course times, dates, and locations. All information submitted will be confidential, and used only for purposes of mentor selection. All mentor applicants selected must attend an orientation session before beginning the mentor process with EPI candidates. Florida statute requires that all mentors hold a valid professional teaching certificate, complete clinical educator training, and have at least three years of successful teaching experience.

Please respond to each item below, then submit the form via the button at the bottom.
First Name:
Middle Name:	(not initial or maiden)
Last Name:
Birthdate MM/DD/YYYY:
Street Address:
Address (cont.):
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip/Postal Code:
Country:
Work Phone:
Home Phone:
Cell Phone:
E-mail:
Current Job Title / Grade Level / Subject:
School/Organization:

1. What is your highest college degree?
   Bachelor'sMaster'sSpecialist'sPh.D.-Doctorate
2. What is the title of your degree and the name of the college from which you graduated?
   
3. Which of the following best describes you? (click the drop-down arrow and select)
   I have taught 0-3 years in a K-12 setting. I have taught 4-7 years in a K-12 setting. I have taught 8-12 years in a K-12 setting. I have taught 13-20 years in a K-12 setting. I have taught 21 or more years in a K-12 setting
4. What grade level do you plan to teach, or currently teach?
   Select any of the following options that apply:
   Pre-KK-4567-89-12
5. Please indicate the subjects/levels in which you are currently teaching.
   Agriculture 6-12Art K-12Biology 6-12
   Chemistry 6-12Computer Science 6-12Drama 6-12
   Ed. Media Specialist PK-12Elementary Education K-6English 6-12
   Exceptional Student Ed. K-12Business EducationFamily and Consumer Science
   French K-12Guidance and Counseling PK-12Health K-12
   Hearing Impaired K-12Industrial Arts-Tech. Ed. 6-12Journalism 6-12
   Latin K-12Mathematics 6-12Middle Grds English 5-9
   Middle Grds Gen. Science 5-9Middle Grds. Mathematics 5-9Middle Grds Social Sci. 5-9
   Music K-12Physics 6-12Prekindergarten/Primary PK-12
   Preschool Ed. (Birth-Age4)School Pyschologist PK-12Social Science 6-12
   Spanish K-12Speech-Language Impaired K-12Visually Impaired K-12
   
6. If you are currently employed in a district school system, please enter the name of your school (in not please leave blank):
   
7. In which county would you prefer to teach?
   BayGulfFranklin
   Other Florida CountyOutside StateNo Preference
   
8. Provide the date that you completed Clinical Education Training.
   
9. Take a moment to share with the EPI Mentor Selection Committee why you are interested in becoming a mentor for the Educator Preparation Institute.
   
10. What specific strengths/experiences/credentials do you have that make you desirable as a mentor to those entering teaching careers? Please indicate if you are a National Board Certified Teacher.
    
11. Is there anything else you'd like to share with the EPI Mentor Selection Committee, comments, or concerns? (Also, use this box to highlight areas in which you are currently teaching but do NOT hold certification.)