Certification Centrals Mentoring Program

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Thank you for participating in Certification Central’s mentoring program!

Your participation will include the following:

•    Meeting virtually at least once each semester, as well as on-demand to meet your specific and timely needs;

•    Observing your teaching once each semester, virtually or onsite;

•    Reviewing the following records: annual teaching evaluation, progress monitoring of at least 2 students (diagnostic report/IWAR,      IEP, quarterly progress reports);

•    Redacting any identifiable information of P-13 students; and

•    Receiving a $250 stipend at the completion of each year.

Your participation is voluntary and may be withdrawn at any time. Information obtained will be used for accreditation purposes only. Information will be reported in aggregate with no identifiable data reported (i.e., names of participants, names of schools).

By submitting this form, you are agreeing to participate in CC’s mentoring program based on the terms listed above.

Please provide us with the following information:

Date *

Name *

First

Last

Email *

Participant’s Current Position *

School *

School Address *

Address Line 1

Address Line 2

City

State

Zip Code

School Phone Number *

Name of School Mentor/Supervisor *

First

Last

Email of School Mentor/Supervisor *

Select the type of school where you are teaching or will be teaching

Public
Private
Rural
Urban (must encompass at least 2,000 housing units or have a population of at least 5,000)
Bureau of Indian Education/Reservation
Virtual

Select the Percentage of Free & Reduced Meals for Your School *

Approximately ¾ of the student population receives free/reduced lunches
Approximately ½ of the student population receives free/reduced lunches
Approximately ¼ of the student population receives free/reduced lunches

Select the Primary Race of the Student Population in Your School *

White, non-Hispanic
Black or African American, non-Hispanic
American Indian/Alaska Native, non-Hispanic
Asian, non-Hispanic
Native Hawaiian/Pacific Islander, non-Hispanic
Hispanic, regardless of race
Two or more races, non-Hispanic

What is your age (NCES) *

Less than 30 years
30-49 years
50-54 years
55 years or more

Gender at Birth *

Male
Female

What is your race? *

White, non-Hispanic
Black or African American, non-Hispanic
American Indian/Alaska Native, non-Hispanic
Asian, non-Hispanic
Native Hawaiian/Pacific Islander, non-Hispanic
Hispanic, regardless of race
Two or more races, non-Hispanic

Socioeconomic status *

Low (less than $52,200)
Middle ($52,300 to $156,600)
High (More than $156,600)

Were you a paraprofessional before becoming a special education teacher? *

Yes
No

If you answered yes on the previous question, how many years were you a paraprofessional before becoming a special education teacher? *

Were you a special education technician before becoming a special education teacher? *

Yes
No

If you answered yes on the previous question, how many years were you a special education technician before becoming a special education teacher? *

Thank you for participating in Certification Central’s mentoring program!

Your participation will include the following:

Your participation is voluntary and may be withdrawn at any time. Information obtained will be used for accreditation purposes only. Information will be reported in aggregate with no identifiable data reported (i.e., names of participants, names of schools).

By submitting this form, you are agreeing to participate in CC’s mentoring program based on the terms listed above.

Please provide us with the following information:

Thank you!