Peer Coaching Program Application Form
Please respond to the questions on both sides of this form. The information you provide will assist in pairing you with a Peer Coach, assist the Coach in understanding what you hope to gain from this experience, and provide a basis for discussion at your first meeting.
Please send completed form to Sally Lange in the LEARN Center (2015 Roseman). A copy will be returned to you prior to your first meeting with the Peer Coach.
Download Peer Coaching Program Application Form in Word format
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Personal
Name:_____________________________________
Email:_____________________________________
Department:________________________________
Campus Office:____________________________
Campus Phone:_____________________________
Schedule for Semester (Course Titles, Days, Times, Rooms)
Background
Describe briefly the context for your peer coaching experience. (e.g., How long have you been at UW-Whitewater? How long have you been a full-time instructor? Are you responsible for primarily upper or lower division courses, large lecture or small seminars, etc? Why enroll in peer coaching now?)
Describe your instructional philosophy. (e.g. How do you believe students learn best? What do you value happening in and out of the classroom?
Based on feedback from student evaluations, peer evaluations and self-reflection, what would you identify as your strengths as an instructor?
Based on feedback from student evaluations, peer evaluations and self-reflection, what would you identify as areas where you might improve as an instructor?
Goals
By participating in this program, what goals (at this point) do you hope to achieve or what questions would you like answered relative to your instruction specifically, and student learning?
I would prefer a Peer Coach from the following discipline-based area (check, at least, one of following):
_____Arts
_____Business
_____Education
_____Human Services
_____Humanities
_____Natural Sciences
_____Social Sciences
_____I have no preference
Term Prefer Peer Coach:
_____Spring 2012
_____Fall 2012
_____Spring 2013
_____Fall 2013
_____Spring 2014
_____Fall 2014
