P.O. Box 5604
P.O. Box 5604
928-523-2359
Flagstaff, AZ 86011-5604
928-523-5991 fax
www.nau.edu/roadscholar
Week Attending:
Monument Valley High School Service
QUESTIONNAIRE FOR NAVAJO YOUTH EDUCATION SERVICE PROGRAM
Please type in your answers
save document to your desktop
email it as an attachment (or scan
and send) to Principal, Pat Seltzer at pseltzer@sanjuanschools.org (If you have problems opening the
link, hold Ctrl button on your key board and click with your mouse). Put Road Scholar, ‘MVHS’ and the
program start date in the subject line
OR
Fill it out online, print it out (saving it if you want) and mail it to:
Principal Pat Seltzer
Monument Valley High School
PO Box 360008
Monument Valley, UT 84536
Note: Health and Safety Form is returned to NAU Road Scholar separately.
The information below is important to the success of this school-based program offered through
NAU Road Scholar Service Programs. Your coordinator, along with with Monument Valley High School
staff, will use this information to prepare in advance for the program. Thus, it is very important to indicate
clearly which subject you would like to work with.
Remember – your job and life experiences can be interesting to the students so don’t limit yourself
because you feel your job or life was not glamorous or fascinating. All life experiences are important,
whether it is raising a family, or out in the working world, or both. If you have information, videos, slides,
photographs or any other materials, please bring them with you. If you are a performing artist and wish to
present a performance, read stories or teach poetry, please let us know so that we may try to schedule
your activity.
1)
Name:
2)
Address:
3)
Current/former vocation / profession:
4)
Phone #:
5)
E-mail:
6)
With which subject(s) would you especially like to help the students? We encourage you to check
more than one subject, # in order of preference. This will be used to place you with a teacher.
1.
PE / Health
2.
Language Arts
3.
Special Education
4.
Reading
5.
Art
6.
Agriculture
7.
Computer Lab
8.
Woodshop/Drafting
9.
Music
10. History
11.
13.
15.
17.
7)
Science
Math
Performing Arts
Other
12.
14.
16.
18.
Photography
Automotive
Home Economics
Other
Sometimes you cannot be placed in an area of choice. Is there anything you feel you cannot do? If so,
please cross out those numbers above.
8)
What age group are you most comfortable working with?
7th Grade
10th Grade
8th Grade
11th Grade
th
9 Grade
12th Grade
9)
Is there any grade you would feel uncomfortable working with?
10)
If your strength is in Math, what level or levels would you be able to tutor? Pre-algebra - Calculus III.
11)
If you chose Special Education, what background, if any, do you have working with developed mentally
disabled?
12)
If you chose Art, what media or mediums do you work with?
13)
If you chose Music, please specify which area of music you will be able to tutor?
14)
Please let us know of any specific experiences related to classroom subjects you would like us to know
about.
15)
What are your hobbies and interests? Do you plan to bring supplemental information with you, such as
videos/slides, etc.?
16)
What are your expectations of this program?
17)
Have you visited the Navajo Reservation before?
18)
What professional / life experience would you like to share with the students? If you want to work in the
classroom, would you like to give a short presentation in your field of interest? If so, what would the
subject be? Remember to gear it to high school (grades 7-12). This is optional and NOT a requirement of
participation in the program.
19)
Please list here any special equipment you may need for a presentation: slide projector, laptop and
digital projector, etc. so that the school and coordinator may prepare appropriately for your visit to the school.
20)
Please write a short biographical sketch that we can share with the staff at MVHS. Include experience
you may have working with students.
Monument Valley High School encourages participants to contact their schools with any questions or concerns.
Please return completed questionnaires or e-mail ASAP to:
Principal Pat Seltzer
Monument Valley High School
PO Box 360008
Monument Valley, UT 84536
(435) 678-1845/435-678-1208
Fax (435) 678-1258
pseltzer@sanjuanschools.org
(reference Road Scholar, MVHS Questionnaire and date in subject line)
Note: Health and Safety Form is returned to NAU Road Scholar separately. 20110112.jb