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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?

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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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