Mentor/Content Leader Registration Request (next step: Register for classes at https://www.latechcrrc.org/mtcl.html)

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* 1. Last Name

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* 2. First Name

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* 3. Middle Initial

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* 4. Title

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* 5. School Name

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* 6. District Name

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* 7. Grade(s) Taught (19-20 academic year)

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* 8. Subject(s) Taught (19-20 academic year)

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* 9. List certifications held

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* 10. What training are you requesting to pursue?

Mentor Leader Training (Fall Course, Winter Course)

ELA Content Leader Training (Fall Course, Winter Course)

Mathematics Content Leader Training (Fall Course, Winter Course)

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* 11. Currently a mentor?

I will be mentoring a Louisiana Tech Resident in my classroom.

I will be mentoring a Louisiana Tech MAT intern.

I will be mentoring a resident or intern from another preparation program.

I am mentoring a new teacher at my school/in my district.

I am mentoring an assigned teacher in need of remediation.

I would like Louisiana Tech to assign someone I can mentor!

Please explain if you do not fit one of the above criteria.

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* 12. Registration Preference

I would like to come to campus another day to complete paperwork.

If my district is hosting a sign up day, I would prefer to complete paperwork there.

I am happy to complete registration online independently and mail any necessary papers to campus for you.

Other (please specify)

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* 13. I understand that there will be a cost to register for thes graduate courses, and that I will receive a bill. It is my responsibility to secure funding and reimbursement from my school district, principal, etc. (Estimated cost: $800-$1,000.)

Yes, I understand I will receive a bill.

Signature (Understanding of Financial Obligation)

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* 14. Permanent Mailing Address

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* 15. CIty

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* 16. State

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* 17. Zip Code

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* 18. School Email

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* 19. Personal Email

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* 20. Cell Phone

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* 21. I hold Louisiana's Supervision of Student Teaching Certification

Yes

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* 22. I have completed Louisiana Tech's TEAM Model Mentor Training

Yes

I would like to participate in the future.

If you participated previously, please list the year.

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* 23. Contact Name/Email/Phone for Immediate Supervisor( Principal? District Leader?)

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* 24. Next Steps:: Register at https://www.latechcrrc.org/mtcl.html
We hope this process is helpful. We are available via email if you have any questions: (Lisa) ldick@latech.edu or (Amy) avessel@latech.edu

Mentor/Content Leader Registration Request (next step: Register for classes at https://www.latechcrrc.org/mtcl.html)

Question Title

* 1. Last Name

Question Title

* 2. First Name

Question Title

* 3. Middle Initial

Question Title

* 4. Title

Question Title

* 5. School Name

Question Title

* 6. District Name

Question Title

* 7. Grade(s) Taught (19-20 academic year)

Question Title

* 8. Subject(s) Taught (19-20 academic year)

Question Title

* 9. List certifications held

Question Title

* 10. What training are you requesting to pursue?

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* 11. Currently a mentor?

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* 12. Registration Preference

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* 13. I understand that there will be a cost to register for thes graduate courses, and that I will receive a bill. It is my responsibility to secure funding and reimbursement from my school district, principal, etc. (Estimated cost: $800-$1,000.)

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* 14. Permanent Mailing Address

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* 15. CIty

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* 16. State

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* 17. Zip Code

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* 18. School Email

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* 19. Personal Email

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* 20. Cell Phone

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* 21. I hold Louisiana's Supervision of Student Teaching Certification

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* 22. I have completed Louisiana Tech's TEAM Model Mentor Training

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* 23. Contact Name/Email/Phone for Immediate Supervisor( Principal? District Leader?)

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* 24. Next Steps:: Register at https://www.latechcrrc.org/mtcl.htmlWe hope this process is helpful. We are available via email if you have any questions: (Lisa) ldick@latech.edu or (Amy) avessel@latech.edu

* 24. Next Steps:: Register at https://www.latechcrrc.org/mtcl.html
We hope this process is helpful. We are available via email if you have any questions: (Lisa) ldick@latech.edu or (Amy) avessel@latech.edu