Mentor Connections Teaching Guidance

Mentor Connections

Teaching Guidance Video Review
Student Profile

Please respond to all questions that apply
Student First Name: *
Total Years of Piano Study*
Student Level*
Student Age*
Challenges and Concerns (select any that apply):

Student with special needsTransfer studentTechniqueReading and rhythmRepertoireSound productionArtistryLearning processBehaviorMotivationCommunicationOther
Describe the specific challenges and your concerns with this student, as depicted in this video (200 words or less).*

0/200
Describe the strategies and approaches you have tried to solve this problem (200 words or less).*

0/200
List the overall activities featured in the video(s) in the order they appear (80 words or less).

0/80
List any books and pieces used in this lesson video. Please include titles and composers of any repertoire featured (80 words or less).

0/80
Teacher Profile
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Time Zone*
Scheduling Constraints*
Are you currently a student?*

YesNo
How many years have you worked with this student?*
Total years teaching *
Video Submission
Format of the video (select one)*

Lesson segment(s) from one lessonLesson sequence from multiple lessonsOne complete lesson
Video links (copy and paste links to a shared file on YouTube, Vimeo, Google Drive, or DropBox)*
Total length of the video in minutes *
A maximum of fifteen minutes of video will be reviewed. If there are specific segments to review, please indicate specific time codes. Otherwise, the mentor will view the first fifteen minutes.
Permissions
Electronically sign each statement below with your initials to acknowledge your agreement and consent.
It is the responsibility of the submitter to secure permission for any students appearing in the video. By initalling here, you acknowledge your responsibility in attaining such consent.*
I have read and agree to the policies and procedures of Mentor Connections (see below).*
Policies and Procedures
I hereby consent to authorize the Frances Clark Center and its mentors to use the submitted video(s) and/or file(s) for this mentorship service and for no other purpose.*
I hereby consent to authorize the Frances Clark Center and its mentors to record the video conference with me, as long as its contents remain confidential.*
Options & Pricing

Options*

30-minute individual conference$45.00

45-minute individual conference$60.00

60-minute individual conference$75.00

Enter coupon

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Difficulties with this form? Email arucker@francesclarkcenter.org
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