Request for Change Form
The Butte County Office of Education Teacher Induction Program strives to provide high-quality mentors for all induction candidates. If, for any reason, a participating teacher or mentor wants to change the candidate/mentor match, the following form must be completed by the individual requesting the change:
Email address *
Candidate's Information
Candidate's Name *
Your answer
Name of District *
Your answer
Name of School *
Your answer
Grade Level/Subject Taught: *
Your answer
Phone Number *
Your answer
Mentor's Information
Mentor's Name *
Your answer
Name of District *
Your answer
Name of School *
Your answer
Grade Level/Subject Taught *
Your answer
Phone Number *
Your answer
Concerns
My concerns are: *
Your answer
I have attempted to resolve the situation by: *
Your answer
I request your intervention in the following: *
Your answer
Assurance:
By initialing below, I am requesting a review of my current participating teacher/mentor match. I understand that the process involves the Director of the Butte Teacher Induction Program meeting with both myself and the candidate/mentor to discuss my concerns.
Candidate's/Mentor's Initials *
Your answer
A copy of your responses will be emailed to the address you provided.
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