DISTANCE LEARNING Mentor Teacher Application

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Name: ________________________

Home Address:

______________________________

______________________________

Home Phone: ___________________

School:________________________

School District:__________________

School Address:

_______________________________

_______________________________

County: ________________________

School Phone: ___________________

FAX: __________________________

Email: _________________________

State Legislators:

_______________________________

_______________________________

_______________________________

What grade level(s) do you teach? _________

What subject(s) do you teach? __________________________

What leadership experiences have you had?

Do you have access to a computer?_____
Do you have access to email?______
How comfortable are you with email? very - some - not at all
Do you have access to the internet?_____
How comfortable are you with Internet? very - some - not at all

Will you be available throughout the year to answer questions from teachers in your region of the state? ______

Any anticipated leaves of absence or vacations?____ If yes, when?_________________

Why are you interested in a mentor teacher position and what will you bring to the program?

Visit the JASON Homepage at: www.jasonproject.org

Please return to:
DISTANCE LEARNING
James Ford Bell Museum of Natural History
10 Church Street SE
Minneapolis, MN 55455
FAX: (612) 626-7704

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