1.	LAST NAME*

2.	FIRST NAME*

3.	2013-2014 SCHOOL* If you are unsure of your assigned location, please choose the name of your current home school. Contact Ginger Kave if the assignment changes.
	--Please Select--Academy of ScienceAldieAlgonkianArcolaAshburnBall's BluffBannekerBelmont RidgeBelmont StationBlue RidgeBriar WoodsBroad RunBuffalo TrailRosa Lee CarterCatoctinCedar LaneJohn ChampeCool SpringCountrysideCreighton's CornerKenneth W. CulbertDiscoveryDominion HighDominion TrailFrederick DouglassEagle RidgeEmerickEvergreen MillFarmwell StationForest GroveFreedomGuilfordHamiltonHarmonyHarper ParkHeritageHillsboroHillsideHorizonHutchison FarmLeesburgLegacyLibertyLincolnLittle RiverLoudoun CountyLoudoun ValleyLovettsvilleLowes IslandLuckettsJ. Michael LunsfordMeadowlandMercerMiddleburgMill RunC.S. MonroeMoorefield StationMountain ViewNewton-LeePark ViewPinebrookPotomac FallsPotowmackFrances Hazel ReidRiver BendRolling RidgeRound HillSanders CornerSeldens LandingSeneca RidgeJ.L. SimpsonSmart's MillStaff Training CenterSterling ElementarySterling MiddleStone BridgeStone HillSugarlandSullySycolin CreekJohn W. TolbertTuscaroraWaterfordSteuart W. WellerWoodgrove

4.	What grade or subject do you teach? (Special Education teachers, please put Sp.Ed. AND your specific area: Cross Cat, Autism, ECSE, MR., Speech, etc.)* Please notify Ginger Kave if this information changes.

5.	All mentors are required to meet with their protege(s) a minimum of one hour each month outside of contract time in a formal face-to-face meeting. In order to be considered for the position of mentor, you must indicate that you will fulfill the meeting responsibilities. *
	I agree to meet for at least one hour each month with my protege(s) in a formal face-to-face meeting outside of contract time.

6.	GROUP WISE EMAIL ADDRESS:*

7.	HOME STREET ADDRESS*

8.	CITY:*

9.	STATE:*

10.	ZIP:*

11.	HOME or CELL PHONE:*

12.	TOTAL YEARS TEACHING:*
	--Please Select--12345678910111213141516171819202122232425262728293031323334353637383940

13.	TOTAL NUMBER OF YEARS TEACHING IN LCPS*
	--Please Select--12345678910111213141516171819202122232425262728293031323334353637383940

14.	NUMBER OF YEARS AS AN LCPS MENTOR*
	--Please Select--01234567891011121314

15.	All mentors must attend a total of four hours of professional development. ALL APPLICANTS WHO HAVE NEVER PARTICIPATED AS AN LCPS MENTOR MUST ATTEND A TRAINING WORKSHOP IN ORDER TO BE ELIGIBLE TO MENTOR IN THE 2013-2014 SCHOOL YEAR. Each applicant must select one of the following.*
	I have never been an LCPS mentor and will attend a summer training session by enrolling on My Learning Plan. I am an experienced mentor and will select 4 hours of Professional Development throughout the school year that is relevant to mentoring.

16.	I wish to be considered for the position of Lead Mentor for my school.Selected Lead Mentors will be notified by June 1. New Lead Mentors must attend one of the workshops designed specifically for Lead Mentors; dates TBA.Veteran Lead Mentors will attend one of the 2-hour L.M. refresher sessions; dates TBA. Workshops will not be listed in My Learning Plan until lead mentors have been appointed.
	--None--Yes No