Mentoring Pairs for Child Care

Supervisor Matching & Participation Form

Community Name: Region of Waterloo

Funded through The Region of Waterloo

The information that you provide will be treated confidentially and used in an aggregate form only. This data will be used to inform the actual mentoring process and report on the Mentoring Project.

Declaration

I have obtained permission from board/owner to participate in Mentoring Pairs for Child Care.

I agree to participate in 8 hours per month for the mentoring process and components, including study groups, connecting with mentoring pair, pair sharing conversations, watching videos, surveys, and participating in all evaluations, etc.

I agree to my email and centre name being shared with my mentoring pairs community.

Are you applying to be a Mentor (5 or more years experience as a Supervisor) or a Mentee (less than 5 years experience as a Supervisor)?

Mentor

Mentee

Contact Information

Personal Information

First Name

Last Name

Position

Home Phone

Preferred Email

Your Licensed Child Care Centre's Information

Centre's Name (Select from list below.)

Street Address

City

Province

Postal Code

Phone

Ext.

Centre's Email

Other Information

Professional Profile

A. Professional ActivitiesWhich of the following activities are you involved in?

Supervising students on placement

Participating in a community planning committee

Volunteering on a related board of directors team

Member of a professional association

Teaching in a college or university

Supporting facilitation of workshops or networks in your community

Not involved in any of the above

B. Work Experience

Number of years working in the ECE field in any position

Number of years working in the role of Supervisor

C. Professional GoalsPlease select the top 3 professional goals.

D. Topic of InterestPlease select your top 3 professional learning interests.