VA-CEC Mentor Interest Form
If you are an experienced special education teacher (5+ years of experience) and are interested in serving as a special education mentor through Virginia CEC, please fill out the interest form below.
Email *
What is your full name? *
What is your current job title? *
In what district or institution do you teach or work? *
Are you a current or former special education teacher in Virginia? *
What type of teacher preparation program did you complete? *
How many years of experience do you have in teaching special education (not including student teaching, teaching general education, or serving in a role other than teacher)? *
What is your racial/ethnic background? (select all that apply)? *
Required
What grade level(s) do you have experience teaching (select all that apply)? *
Required
If you teach a specific subject or content areas (i.e., math, reading), what subjects do you have experience teaching? If you taught all subjects (for example, as an elementary teacher) you can leave this blank. 
What disability categories do you have the most experience with? (If you taught students with a variety of disabilities, select the option that you feel most skilled in) *
What other disabilities do you have experience with? *
Required
In what areas do you feel you could provide the most support (select all that apply)? *
Required
Are you committed to virtually meeting with your mentee a minimum of 4 times per semester? *
Have you previously served as a mentor in a formal mentoring program? *
Have you previously served as a cooperating teacher for a student teacher or intern? *
Have you completed previous mentor training? *
As in incentive for serving as a mentor, which would you like to receive? *
Is there anything else you would like us to know about your mentoring abilities? *
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