College of Education and Psychology
Educational Field Experiences
118 College Drive #5028
Hattiesburg, MS 39406-0001
601.266.4571
www.usm.edu/efe
MENTOR TEACHER SCHOLARSHIP FORM
Name: _________________________________________________________ Date: _____________________
Last
(Maiden)
First
Middle Initial
Social Security: __________________________________________________ Student ID: ________________
Mailing Address: ____________________________________________________________________________
Street, P.O. Box, Route #, Apt. #
City
State
Zip
E-Mail Address: __________________________________________________ Phone: ___________________
School: _____________________________Principal: ___________________ Phone: ___________________
School District: ______________________ Subject: _____________________ Grade Level: _______________
# Semester Hours Requested
(6 hours maximum):
______ Graduate
______ Undergraduate
______ Continuing Education
______ Online
Year/Semester:
Campus:
_____ Fall
_____ Hattiesburg
_____ Spring
_____ Long Beach
_____ Summer
USM Course Registration Date: ___________________________
Have you previously registered for a Mentor Teacher Scholarship? Yes____ No_____ If so, what year? __________
Please return this form to:
Attn: Mentor Teacher Scholarship
Educational Field Experiences
118 College Drive #5028
Hattiesburg, MS 39406-5028
1. Supervision of a teacher candidate (student teacher) qualifies you to apply for a scholarship
through Educational Field Experiences (EFE) for coursework at Southern Miss. If granted a
scholarship, you are still responsible for the payment of online, lab, parking, late registration,
interest, and certain specialty course fees.
PLEASE NOTE: Scholarship application forms will be date stamped upon arrival to EFE.
Scholarships will be awarded based upon:
a.
available funds;
b.
a first-come, first-served basis; and
c.
a maximum of 2 scholarships (6 credit hours) per applicant per semester.
2. It is important to register for your course with the University before you submit the scholarship
form to EFE. Once you have submitted your scholarship form, please contact EFE for
confirmation that it has been received.
3. Registration for the course is completed through standard USM registration channels. If you need
assistance with registration, please contact the College of Education and Psychology Dean’s
Office at (601) 266-4224.
PLEASE NOTE: Processing the Mentor Teacher Scholarship form with EFE does not enroll you
in a Southern Miss course.
4. Scholarship awards will be determined no later than the first two weeks of class.
5. EFE will notify you via email if your scholarship is awarded.
6. If you get a bill, please do not ignore it. Call EFE at (601) 266-4571 for clarification and support.
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7. In order to qualify for a three (3) semester hour scholarship, the scholarship applicant must have
mentored a USM student teacher during Fall 2004 - Spring 2012.
8. In order to avoid late fees, please register with the University and apply to EFE the semester prior
to taking a class.
FINAL DATES FOR SUBMISSION OF SCHOLARSHIP APPLICATIONS:
a. Fall 2015 courses – Monday, August 24, 2015
b. Spring 2016 courses – Friday, January 22, 2016
c. Summer 2016 courses - Friday, June 3, 2016
FOR OFFICE USE ONLY
__________________Date Processed
__________________Semester Hours Awarded
Dates of MT credit used for the above request (list semester/year): ____________________________________________________________________
Previous MT credit awarded (list semester/year):___________________________________________________________________________________
Remaining MT credit to date (list semester/year): __________________________________________________________________________________
I have read and understand the Mentor Teacher Scholarship Application Procedure form.
_____________________________________________
Name
______________________
Date
Notes:
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