Fayetteville State University
Supplemental Instruction (Returning) Leader Application
Please print neatly
This complete application, with completed faculty recommendation form, must be
submitted by April 15, 2011 to Ms. Jessica Star-Russell.
Section 1: Personal and Academic Information
Full Name: (First, MI, Last)
Permanent Address: (Including Zip Code) This address will go on contract
Permanent Phone #:
Classification in SPRING 2011? (circle one)
Academic Major:
Cell Phone #:
sophomore
junior
senior
grad
Academic Minor:
Course AND Section for which you are applying:
Name of Instructor for above class/section:
Section 2:
1) Please list and explain any activities/clubs/jobs/obligations you will have next
semester in addition to working with the Supplemental Instruction Program. (Please
include as best you can the time commitments involved with each).
2) Please attach to this application a copy of your Fall 2011 class schedule AND a
Recommendation Form from the instructor with whom you are applying to work.
With my signature below, I affirm that 1) I have read and understand the requirements and
responsibilities of SI Leaders. 2) All of the information provided is complete and accurate. 3) If
selected for this program, I understand that I must attend an initial meeting.
Signature: ____________________________________ _ Date: ________________________
**Failure to submit this application by the deadline will represent a resignation as a SI leader**
Fayetteville State University
Supplemental Instruction Leader - Recommendation Form - 1
To the student: Complete Section I of this form and submit it to an individual qualified to
evaluate your potential as a Supplemental Instruction Leader. After completing the form, the
individual should return the form to you in a sealed envelope with his or her signature across
the sealed flap. You should submit the completed recommendation form with your application.
Section I: Student Full Name: __________________________________________
Course and section number for Fall 2011 in which you propose to serve as
Supplemental Instruction Leader: _________________________________________
I (check one) ___ waive, ___ do not waive my right to review this document:
Signed: ________________________________________ Date: ______________
Section II. To the Individual Completing this form:
The above named student has applied for a position as Supplemental Instructor for the courses
indicated. Please complete the following evaluation of his or her potential to serve effectively as
Supplemental Instructor.
How long have you known this student? ______ In what capacity? _________________
Has this student completed a course you taught? ____Yes ____No
If “yes,” what was the course and final grade? __________________________________
Please evaluate the student on each of the following characteristics:
Poor
Fair
Good
Academic Ability
Dependability
Maturity
Communication Skills
Ability to work with others
Overall evaluation
Excellent
Signed: ____________________________ Position: _____________________________
Phone Number: ______________________ Date: ____________________________
Please place this completed form in an envelope; seal the envelope, and sign over the sealed flap.
Return the sealed envelope to the student for submission with the application. If you have any questions,
please contact Jonathan Walker at ext 2007 or panderso@uncfsu.edu. Thank you.
Deadline for submitting application and recommendation forms: Friday, April 15, 2011