Madison Area Technical College

MADISON AREA TECHNICAL COLLEGE REQUEST FOR PRIOR APPROVAL OF CERTIFICATION RENEWAL ACTIVITY (Use one form per activity) (NOTE: THIS FORM IS FOR CERTIFICATION ONLY AND DOES NOT APPLY TO SALARY ADVANCEMENT)

Name: ______Date: ___Academic year 2006- 2007______Address: CERTIFICATION RENEWAL ACTIVITY (Check One) I. ____ Academic Coursework II. ____ Continuing Education

III. ____ Work Experience IV. _x___ Professional Growth (check section plan under Which activity falls) __ _ A. Workshop, conference, seminar ____ B. Teaching Experience __x_ C. Professional Service ____ D. Professional Speaking ____ E. Cross-training ____ F. Special Assignment ____ G. Print & Other Media Productions ____ H. Leadership Role ____ I. Curriculum/Instruct Innovation ____ J. Consultant Evaluator ____ K. Research & Development ____ L. Technical Updating ____ M. Externships ____ N. Professional Exchange Program ____ O. Mentor ____ P. Sundry Activities

Describe Activity: Outcomes of Faculty Mentoring Program To orient new Full Time Faculty to the MATC work environment in an open and supportive manner. To foster healthy work relationships and a fuller understanding of the scope of a Full Time faculty member’s work. To create a pairing of new FT faculty with veteran “positive” affirming FT faculty. To foster open communication between mentors and mentees by providing ongoing support from Professional Development. To provide continuous improvement via assessment of the mentoring process which helps us serve our students.

Indicate Number of: Date/s of Activity: __ Academic year 2006- 2007______2__ Credits or ____ Hours Verification will be by: __Wm. Patrick Barlow______

Official transcripts of coursework should be mailed to: Kristin Gebhardt, MATC Human Resources Office, 3550 Anderson Street, Madison, WI 53704 Date: ______Approved: ______Disapproved: ______

Signature of Human Resources Office: ______

Verification of Participation: For workshops/conferences you may wish to have the presenter or proper official verify participation by completing the following section: I HEREBY VERIFY (Name) Gail Bailey PARTICIPATED IN THE PROFESSIONAL GROWTH ACTIVITY DESCRIBED ABOVE.

_Staff and Organizational Development Coordinator _Madison Area Technical College_ (Title) (Organization)

(Signature)