San Diego County Office of Education

San Diego County

Designated Subjects Credential Consortium

6401 Linda Vista Road, Room 308, San Diego, CA 92111-7399

Program Mentor Application

Personal Information

Name of Mentor:

Last Name First Name Middle Name

Address:

Street Address City ST Zip

Phone : ( ) ( ) ( )

Home Work Message/Alternate

Email Address:

Social Security Number: Date of Birth:

Employment Information

Check the agency, or district, requesting you to apply for mentor approval. Obtain recommendation from employer.

SAN DIEGO SCHOOL DISTRICTS

p  Borrego Springs Unified p Carlsbad Unified p Coronado Unified

p  Escondido Union p Fallbrook Union p Grossmont Union

p  Julian Union p Mountain Empire Unified p Oceanside Unified

p  Poway Unified p Ramona Unified p San Diego Unified

p  San Dieguito Union p San Marcos Unified p Sweetwater Union

p  Valley Center-Pauma Unified p Vista Unified p Warner Unified

OTHER AGENCIES/DISTRICTS

p  California Department of Corrections, Institution:

p  California Youth Authority

p  San Diego County Office of Education

p  San Diego Job Corps.

p  Other:

p  None

LEA USE ONLY:

Requirement Information:

TEACHING EXPERIENCE ~ Please provide verification of at least 3 years of successful teaching.

Employer Dates of Employment

CREDENTIALS HELD ~ Please all credentials you currently hold.

Credential Expiration Date

RECENT EXPERIENCE ~ Please describe your recent educational experience.

OTHER INFORMATION ~ Use the area below to tell us anything else pertinent to this application.

HOW TO APPLY TO BE A PROGRAM MENTOR FOR THE

SAN DIEGO COUNTY

DESIGNATED SUBJECTS CREDENTIAL CONSORTIUM

Obtain a recommendation from a partnering school district representative to be a Designated Subjects Program Mentor.

Collect application materials to be submitted. Use the following guide as a checklist for your application packet.

Applications & Materials

¨ Program Mentor Application (this form)

¨ Recommendation from a partnering school district

¨ Verification of three (3) years of successful teaching

¨ Copies of all current credentials

¨ Any other supporting documentation relevant to this application

Submit entire packet to the San Diego County Designated Subjects Credential Consortium at:

San Diego County Office of Education

6401 Linda Vista Road, Ste. 308

San Diego, CA 92111

Mentor Teacher Application.doc Page 2 of 3 11/16/16