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Mentor Teacher Application
1. Last Name:
2. First Name:
3. School:
4. District:
Charlotte-Mecklenburg Schools, NC
Cherokee
Chester
Clover (York #2)
Fairfield
Fort Mill (York #4)
Lancaster
Rock Hill (York #3)
Union, SC
Union, NC
York (York #1)
Other: please list below
5. School District E-mail address:
6. Grade:
7. Subject:
Art
Dance
Early Childhood
Elementary
English-secondary
Math-secondary
Middle level language arts
Middle level math
Middle level science
Middle level social studies
Modern languages
Music
Physical Education
Science-secondary
Social Studies-secondary
Special Education
Theater
Other: Please list
8. Concentration: (Example-choral, resource, Spanish, etc.)
9. Certification Area(s):
10. What is the highest degree you have earned? Please list your major/field of study for the option selected. (This information is used for accreditation records only.)
Bachelor's degree
Master's degree
Doctorate degree
11. Years of teaching experience in current grade/subject:
12. List specific time frames of teaching as indicated below. (This information is used for accreditation records only.)
Year started teaching:
If any breaks in teaching, indicate the year(s):
Most recent year of teaching completed:
13. Have you completed at least one year of successful teaching after completing your formal evaluation process (or the equivalent in North Carolina)?
Yes
No
14. Have you attended South Carolina Mentor Training?
Yes
No
15. If you have attended South Carolina Mentor Training, enter the dates of your training and your teaching certificate number below:
Dates of training:
Teaching certificate number:
16. Have you been trained as an ADEPT Evaluator (SCTS 4.0 Evaluator)?
Yes
No
17. If you have been trained as an ADEPT Evaluator (SCTS 4.0) enter the date of your training below:
18. Gender (optional):
Female
Male
Prefer not to answer
19. Ethnicity (optional):
American Indian/Alaskan Native
Asian
Black/African-American
Hispanic/Latino
Native Hawaiian/ Other Pacific Islander
White/Caucasian
Prefer not to answer
20. Being a mentor requires updated knowledge on best practices for mentoring and teacher candidate development. Do you agree to attend and participate in required mentor meetings and/or trainings?
Yes
No
21. List your past experience with teacher development (i.e., mentored teacher candidates, graduate courses, service learning, etc.):
22. The model for clinical experiences at Winthrop University includes the use of co-teaching. List any experience you have with co-teaching (prior experience is not required to become a mentor since training is provided).
After you submit this application and the appropriate recommendations are submitted, you may be contacted to schedule an interview. By clicking the "Submit" button, you certify that the principal of your school is aware of your application, can certify the information you submitted is correct, and supports you serving as a mentor teacher for Winthrop University.
Principal (enter as last name, first name):
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