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GCCC EPI MENTOR APPLICATION
for National Board Certified Teachers

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

Please see 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

 

Please respond to each item below, then submit the form via the button at the bottom.
Please do not alter this field
First Name
Last Name
Middle Name
Date of Birth (MMDDYYYY)
Title
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
Cell
E-mail
Current Job Title/Grade Level/ Subject
School/Organization
1) What is your highest college degree?
Bachelor's Master's Specialist's Ph.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)
4) What grade level do you currently teach, or have you taught?
Select any of the following options that apply:
Pre-K K-4 5 6 7-8 9-12
5) Please indicate the subjects/levels in which you are currently certified. Select any of the following options that apply:
Agriculture 6-12 Family and Consumer Science Middle Grds Mathematics 5-9
Art K-12 French K-12 Middle Grds Social Sci. 5-9
Biology 6-12 Guidance and Counseling PK-12 Music K-12
Chemistry 6-12 Health K-12 Physics 6-12 
Computer Science K-12 Hearing Impaired K-12 Prekindergarten/Primary PK-3
Drama 6-12 Industrial Arts-Tech. Ed. 6-12 Preschool Ed. (Birth-Age 4)
Ed. Media Specialist PK-12 Journalism 6-12 School Psychologist PK-12
Elementary Education K-6 Latin K-12 Social Science 6-12 
English 6-12 Mathematics 6-12 Spanish K-12
Exceptional Student Ed.K-12 Middle Grds English 5-9 Speech-Language Impaired K-12
  Middle Grds Gen.Science 5-9 Visually Impaired K-12
6) If you are currently employed in your district's school system, please enter the name of your school (if not please leave blank):
7) In which county do you currently teach?
Bay Gulf Franklin
Other Florida County Outside State  
8) Take a moment to share with the EPI Mentor Selection Committee why you are interested in becoming a mentor for the Educator Preparation Institute.
9) What specific strengths/experiences/credentials do you have that make you desirable as  a mentor to those entering teaching careers?
10) Is there anything else you'd like to share with the EPI Mentor Selection Committee, comments, or concerns?
By submitting this application you acknowledge that there are no guarantees for acceptance as a GCCC EPI mentor.  We are sincerely grateful for your interest in supporting new teachers.  If you are not selected for the first round of mentors, please stay alerted to local media and the college Web site for continuing updates on future opportunities as our program grows.

The deadline for all applications is October 17th.  Selected applicants will be notified in early November.  Classes containing observation components start January 6th, 2006.

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