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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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