EnvironMentors Participant Application
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)
4)____ Subject Matter Expert (1 Hour)
2)____ Project Review Committee (2 Hrs/ Meeting)
5)____ Experimental Design Expert (2 Hrs/ Experimental Design Wkshp)
3)____ Judge (EnvironMentors Fair)
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?
____________________________________________________________
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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
____Soil sampling
____Air quality sampling
____Time Management
____Web Development Skills
____Marine water quality
____Library Research
____Video Documentary Skills
____Writing Skills
____Field Biology Research
____Reading Skills
____Fresh water quality sampling
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
____Low and high rope challenge course skills
____Help to lead a bike ride
____Outdoor leadership skills
____Help to lead flat water canoe/kayak trip
____Leave No Trace certification
____Orienteering and map skills
____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).
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