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Mentoring Database

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Participant Information Form
First Name
Last Name
Address Line 1
Address Line 2
City, State, Zip
Home Phone
Email
Employer
Position/Title
Work Phone
Fax
May we contact you at work?
  Yes      No
I would be willing to:

Share professional expertise in the field(s) of:
  Art
  Business
  Engineering
  English
  Foreign Language / Culture
  Health/Medicine
  Math
  Music
  Physical Education
  Other
  Science
  Social Studies
  Technology

By providing one or more of the following:
  Career Day/Career Fair
  Classroom assistance
  Collaboration, ongoing classroom project
  Community Service Opportunities for Students
  Speaker (to class or assembly)
  Tutoring
  Workplace/Industry tour

DESCRIBE YOUR VISIT - for Publication
Describe what you would be sharing, your expertise
OPTIONAL DESCRIPTION - for Publication
Describe your adventures, hobbies, cultural backgound or generational stories
Do you serve on a District Committee?
such as Budget Review, District Planning Team, etc.
  Yes      No
Grade Levels
Check one or more groupings you would be interested in working with
  YK-3
  4-5
  6-8
  9-12
Are you willing to present at any school in the District?
  Yes      No
If NO, which school(s) would you be agreeable to:
  DeWitt Road Elementary
  Klem North Elementary
  Klem South Elementary
  Plank North Elementary
  Plank South Elementary
  Schlegel Road Elementary
  State Road Elementary
  Spry Middle School
  Willink Middle School
  Webster Schroeder HS
  Webster Thomas HS
  Private Schools