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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 [email protected] or fax (202-628-4311).
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