In Order to Receive a Monthly Payment of $100.00 for Serving As a Paid Mentor, This Form

Revised 9/2005

In order to receive a monthly payment of $100.00 for serving as a paid mentor, this form must be:

1. Completed monthly by all paid mentors working for the Iredell-Statesville School System.

2. Signed by the mentor, principal/designee, and the ILT to whom the mentor is serving.

3. Submitted with the school’s monthly teacher payroll to the Central Office Payroll Department. Late forms will not be accepted.

I certify that I have performed the following required mentor duties this month:

□ I have completed all monthly requirements as indicated on the Minimum Mentor Timeline and logged each meeting on the Mentor Log Sheet.

□ If applicable I have attended (or been officially excused from attending) all required mentor meetings/staff development training sessions.

Name of Mentor (as it appears on paycheck): ______

School: ______Social Security Number: ______

□ I have either completed mentor training or have made my need for mentor training known to Dreisa Sherrill in the Human Resources Department.

Signature of Mentor: ______Date: ______

Signature of ILT: ______Date: ______

Signature of Principal/Designee: ______Date: ______