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Purpose:

• To specify a set of activities that the graduate student will engage in at the partner campus during the semester
• To establish a record of scheduled activities
• To clarify expectations and responsibilities of both the graduate student and the mentor
• To create a schedule of campus visits amenable to both the graduate student and the mentor

Procedure:

• The graduate student and partner-institution mentor should decide upon a mutually agreeable schedule of visits and activities.
• After the agreement is filled out and signed, two additional copies of the agreement should be made. The graduate student should have a copy; the mentor should have a copy; and a third copy should be given to the Teaching Certificate Director.

Name of graduate student ________________________ Department __________________________

Graduate student contact information ____________________________________________

Name of mentor __________________________________

Institution ___________________________ Department ____________________________________

Mentor contact information ____________________________________________________

Semester and year of mentorship ___________________

Schedule of Visits

Visit One _______________________________________

Visit Two _______________________________________

Visit Three ______________________________________

Visit Four _______________________________________

Additional Visits __________________________________

Selection of Activities
(Note: Schedule the number of activities that you reasonably expect to complete.)

Activity	Date Scheduled	Date Completed

We, the undersigned, have agreed that completing the above schedule of visits and activities is a reasonable goal for the semester.

__________________________________________
(Signature of graduate student)
Date ______________

__________________________________________
(Signature of mentor)
Date ______________

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