Mentor Connections Teaching Guidance

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):

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?

How many years have you worked with this student?

Total years teaching

Video Submission

Format of the video (select one)

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

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Difficulties with this form? Email arucker@francesclarkcenter.org

Mentor Connections

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