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I) Contact Information Name:_____________________________________________________________________

Organization:________________________________________________________________

Title:_______________________________________________________________________

Phone: Home ____________________

Cell _____________________

Work ____________________

Email: Work: ______________________________________________

Alternate: ___________________________________________

Preferred for EnvironMentors Communications?________________________

Home Address_______________________________________________________________

Work Address________________________________________________________________

II) Participation Preference

While developing a strong pool of mentors is our priority, there are a variety of ways that you can participate in EnvironMentors. For descriptions of Participation Options, please see the attached EnvironMentors Participation Option sheet. Please check the way(s) you would like to contribute:

1)____ Mentor (2-3 times a Month)

2)____ Project Review Committee (2 Hrs/ Meeting)

3)____ Judge (EnvironMentors Fair)

4)____ Subject Matter Expert (1 Hour)

5)____ Experimental Design Expert (2 Hrs/ Experimental Design Wkshp)

6)____ Career Advisor (2 Hrs/ Env. Career Wkshp)

Please note what Subject Matter/Workshop/Career that would feel comfortable assisting with: ____________________________________________________________________________

____________________________________________________________________________

Please indicate which Grade Level you would prefer to work with:

____ Freshman ____ Sophomore ____ Junior ____ Senior ____ No Preference

Are you available to mentor during school hours? If so, what days and for how longs?

____________________________________________________________

EnvironMentors Participant Application

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III) Background Info How did you learn about EnvironMentors? _________________________________________ ___________________________________________________________________________ What do you hope to gain from your experience with EnvironMentors? ___________________________________________________________________________ Have you participated in other mentoring, tutoring, teaching, or coaching programs, and/or other forms of youth supervision? If yes, please describe. __________________________________ ____________________________________________________________________________ Do you have any questions or reservations about your role in EnvironMentors? We will do our best to contact you to discuss issues in advance of the program. ________________________ ____________________________________________________________________________ Is there anything else you would like us to know that could help us in the process of matching you with your student. __________________________________________________ ____________________________________________________________________________

IV) Content and Skill Expertise Please check the content areas in which you believe you have basic expertise. A) Content ____General Ecology ____Watersheds ____Estuarine Science ____Marine Science ____Hydrology ____Fresh Water Resources ____Atmospheric Sciences ____Agriculture ____Meteorology ____Air Quality ____Climate Change ____Biogeography ____Toxicology ____Land use ____Soils ____Wildlife Management ____Pollution Prevention ____Ornithology ____Entomology ____Fisheries ____Animal Science ____Botany ____Forestry ____Environmental Justice ____Environmental Health ____ Chemistry ____Other, please note… ________________________________________________________________________

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B) Skills Please check the skill sets in which you believe you have basic expertise ____Project Management

____Time Management

____Library Research

____Writing Skills

____Reading Skills

____Soil sampling

____Web Development Skills

____Video Documentary Skills

____Field Biology Research

____Fresh water quality sampling

____Air quality sampling

____Marine water quality

sampling

____Tree and/or forest

inventory techniques

____ Other, please note

____________________________________________________________________________

V) Field Expertise We always need people willing to help with field trips. Please let us know if you believe you have a sufficient level of expertise sufficient in any of the following areas. ____Help to lead a hike

____Help to lead a bike ride

____Help to lead flat water canoe/kayak trip

____Orienteering and map skills

____Low and high rope challenge course skills

____Outdoor leadership skills

____Leave No Trace certification

____Other, Please note __________________

VI) Education

College/University (Undergraduate)________________________________________________

Degree Program_______________________________________________________________

College/University (Graduate)_____________________________________________________

Degree Program_______________________________________________________________

Post Doctoral Institution/Program _________________________________________________

Additional Professional Development_______________________________________________

Professional Affiliations _________________________________________________________

Foreign Language(s) ___________________________________________________________

VII) Interests/hobbies

Please list interests and hobbies, which will help us get to know you better.

Hobbies: ____________________________________________________________________

____________________________________________________________________________

Music and/or Movies: -____________________________________________________________________________

____________________________________________________________________________

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VIII) Reference Information

Please provide the following information for your immediate supervisor. Name:_______________________________________________Title_____________________ Phone: ( ) ______________ E-mail: ____________________________Years Known:____ Please provide the following information for a colleague or friend Name: _______________________________________________ Relation ________________ Work Phone: ( ) ______________ E-mail ______________________ Years Known: _____ I ________________________________________, give the EnvironMentors Program my consent to contact these individuals and to perform background checks relevant to my participation in their program. Signed: ___________________________________Date of birth ___/___/___

IX) Ethnicity (Optional) __________________________________________

X) Certification I certify that the information contained in this application is true to the best of my knowledge. I agree to undergo a the DCPS criminal background check prior to starting EnvironMentors. This includes completing the Volunteer Application, proof of a Tuberculosis test by a physician (university students may show waiver), and finger printing for background check purposes (Federal Employees with a security clearance can have a waiver letter in lieu of the background check). Please keep in mind that this is for the safety of the students and a requirement of the DC Public School system. Signature: _______________________________________ Date: ___________________ Please return to your local EnvironMentors Chapter Director, Jacklyn Krisch either via email at jshafir@ncseonline.org or fax (202-628-4311).