Mentorship Application

Last Name		First Name		Middle Initial			Social Security #
Street Address/Po Box		City		Zip			Phone #
Alternative Phone #		Pager (text, digital, etc.)			E-Mail
TCDHH Level	RID Level		Since	# Yrs at ACC		# Yrs Professional Experience		# Yrs In Post-secondary

I am interested in becoming a (circle one) Mentor Protégé

for the q Fall of _____ q Spring of _____ q Summer of _____

Interpreter Training: List interpreter-related training from the past 5 years. Include workshops, conferences, study groups, etc. You may use the back of this page for additional space.

Name of Conference/Workshop	Years	Name of Conference/Workshop	Years
		Graduate of IPP? Yes No School:

Preferred Course Content:		Availability:
“X” the courses you prefer to interpret.		“X” the hours you prefer to work.
			Mon	Tue	Wed	Thu	Fri	Sat	Sun
	Art/Art History	8am
	Business/Accounting	9am
	Computers/Programming	10am
	Electronics/CAD	11am
	English:	12pm
	§ Remedial/ESL	1pm
	§ Composition/Literature	2pm
	Government/History	3pm
	Health/Kinesiology	4pm
	Mathematics:	5pm
	§ Remedial	6pm
	§ College Algebra	7pm
	§ Advanced	8pm
	Sciences	9pm
	Social Sciences	10pm

Signature Date

Please return to ACC Interpreter Services. Thank you!

By Mail: Attn: Interpreter Services / 1020 Grove Boulevard / Austin, TX 78741

In Person: Austin Commmunity College / Riverside Campus Room # 9153 / (512) 223-6151