Mentoring Program - Mentor Assignment Acceptance Form

Mentor Teacher Assignment Acceptance Form

This form MUST be submitted by the novice teacher, NO ONE ELSE is able to authorize the payment deduction or the start of mentorship aside from the mentee. Anyone interested in mentoring must complete the online training module ('Training Mentors' - course EI-15540) and supply the certificate number (found on the MyPD page under 'My Transcript') to the novice teacher.
Name of Novice Teacher*

First NameLast Name
Novice Teacher Email*
example@example.com
Novice Teacher Location*
Novie Teacher Assignment Description*
Who will be mentoring you?*

First NameLast Name
What is your mentor's district email address?*
example@example.com
Mentor Teacher Location*
Mentor Teacher Assignment Description*
Mentor Teacher Training Certificate Number*
All prospective mentors must complete the 'Training Mentors' module in Passaic weLearn (course #EI-15540). The certificate number is available under the 'My Transcript' link found on the 'MyPD' page.
Form Submitted By:*

First NameLast Name
Form Submitted By Email*
example@example.com
Are you working under a Certificate of Eligibility (CE) or a Certificate of Eligibility with Advance Standing (CEAS)?*
Hint: If you completed a college field experience and student teaching, you likely hold a CEAS, but check the NJDOE certification status website to be sure.
I certify the information being submitted to be accurate and I authorize the automatic payment deduction ($1000 for CE, or $550 for CEAS, deducted over the next 10 pay periods) corresponding with my certification level. Signature*

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Mentor Teacher Assignment Acceptance Form