Mentor Stipend Request

Mentor Information

Please enter all information as shown in Skyward Employee Access
Campus
Employee ID:
This can be found in Skyward Employee Access
Mentor Full Name:
As shown in Skyward Employee Access
Mentor Email:
example@legacypca.com
First Day of Semester

MonthDayYear
2 digit month, 2 digit day, 4 digit yearEnter the date you physically began working with scholars
Last Day of Semester

MonthDayYear
2 digit month, 2 digit day, 4 digit yearEnter the date you physically stopped working with scholars

Mentee Information

Please enter all information as shown in Skyward Employee Access
Mentee's Name

First NameLast Name
Mentee's Legacy Email:
example@legacypca.com
Meeting Dates
Dates should be entered on a single line and separated by semi-colons.

Mentor Agreement
By signing this document, I hereby certify that I performed the above duty as assigned. I understand that I am required to maintain, in my work files, all documentation which supports the meeting dates provided above as it may be requested of me at a later date to substantiate payment. I also understand that it is my responsibility to obtain, complete, and return this form to my office manager in a timely manner as to allow processing time for the routing of all required signatures. I recognize if this form is received after the specified payroll cut-off date, it will be paid on the following payroll cycle. Finally, I understand that it is against district policy to obtain income from two different sources during the same performance period.
Do you understand and agree to the statement above?
Mentor Signature
This will be your only opportunity to print or save a copy of your submission.

Please select preview PDF to review, print or save a PDF copy for your records.
Payment Information
Rate of Pay
This field will populate based on selection
Budget Code:
Mentor Mesquite West
Mentor Plano
Should be Empty:

Mentor Information