ACSI Leadership U Mentor Application 2023-2024

2023-2024 Mentor Application Form

Name of Applicant:*

First Name

Last Name

LU Program Mentor Level:*

New Mentor Returning Mentor

Photograph

Please attach a recent profile photo.*

No File Chosen

File uploads may not work on some mobile devices.

Any changes to your contact information? (employer, home address, cell phone, etc.?

Yes No

Please indicate any recent changes to your contact information so that we may update our records.

Address:

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Cell Phone*

Home Phone

Preferred Email*

Please indicate the best way to contact you:*

Home Phone Cell Phone Text Email Check All

Name of Current Employer:*

Work Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Work Phone*

Work Email*

Position & Years at Current Employer:*

Supervisor's Name (if applicable)

Previous Employment

Name (Previous Employer #1):*

Address (Previous Employer #1):*

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Title/Position (Previous Employer #1):*

Start/End Dates (Previous Employer #1):*

Supervisor's Name (Previous Employer #1)*

Name (Previous Employer #2)

Address (Previous Employer #2)

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Title/Position (Previous Employer #2)

Start/End Dates (Previous Employer #2):

Supervisor's Name (Previous Employer #2)

Name (Previous Employer #3):

Address (Previous Employer #3):

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Title/Position (Previous Employer #3)

Start/End Dates (Previous Employer #3):

Supervisor's Name (Previous Employer #3)

Education

Name of College/University #1 (Please provide city, state/country)*

Degrees Earned (College/University #1)*

Name of College/University #2 (Please provide city, state/country)

Degrees Earned (College/University #2)

Name of College/University #3 (Please provide city, state/country)

Degrees Earned (College/University #3)

Areas of expertise (Check all that apply):*

Supervision Leadership Organization Research and Report Writing Meeting Facilitation Teaching Check All

Have you been a participant in a mentoring program before?*

Yes No

If yes, please provide name(s) of program(s).

Do you have previous experience working with professional educators?*

Yes No

If yes, please explain your previous experience working with professional educators.

What qualities, skills, or other attributes do you feel you have that would benefit an aspiring school head in the field of Christian education?*

What do you think will be most challenging about becoming a mentor? Contact, proximity? Explain.*

How did you hear about ACSI's Professional Development and Leadership U?*

Do you speak any languages other than English?*

Yes No

If yes, which language(s) do you speak?

Spanish French German Portuguese Japanese Chinese Korean

Other:

For the language(s) checked above, please indicate your proficiency:

Read Write Fluent

Please indicate the location where you currently reside:*

Eastern Division Central Division Western Division Canada International

References

Name (Reference #1):*

First Name

Last Name

Relationship to Applicant (Reference #1):

Years known (Reference #1):

Email (Reference #1):*

Phone (Reference #1):

Name (Reference #2):*

First Name

Last Name

Relationship to Applicant (Reference #2):

Years known (Reference #2):

Email (Reference #2):*

Phone (Reference #2):

Name (Reference #3):*

First Name

Last Name

Relationship to Applicant (Reference #3):

Years known (Reference #3):

Email (Reference #3):*

Phone (Reference #3):

Comments/Additional Information

Comments or Additional Information (optional)