SMI Teacher Information Form

Download an opendocument format copy of this form

Name of cluster ePrincipal here

email: eprincipal@cluster.school.nz

Mobile: insert cellphone number here

Skype: insert skype contact here

Insert Cluster logo here

South Island Cluster Scholarship Mentoring Initiative 2009:

• Mentor teachers information form

The purpose of this form is to gain information which will help planning this year’s SMI programme. Please complete and email (eprincipal@cluster.school.nz) or fax (insert fax number here) back to cluster ePrincipal

Mentor teacher’s Name:
School:
Email address:
Phone (School):
Mobile:
SMI subject:
Preferred time for VC tutorial:
- other available days/times	* * * * *
Specific PD/training requests: e.g using the VC; --use of OLE (Moodle); --teaching online --teaching scholarship --other
MoE Number (on payslip):
Alternatively, I would prefer to be paid (on invoice) to the follow GST registered account	Yes / No Account Name: GST No: Bank Account No:

Insert signature and date here