Smart PDF Form

MENTOR (1 on1) MUSIC LESSONS APPLICATION OF INTEREST
Student's Name:
Instrument(s):
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Name:
Parent e-mail :
example@example.com
Student Cell Phone:
Format: (000) 000-0000.
Parent Cell Phone:
Format: (000) 000-0000.
Grade:
Days Available to Mentor (Check all that apply):
Time Window Available to Mentor for each day available (Afterschool hours):
Length of Per Lesson Preferred:
Name and Contact # of Previous or Current Lesson Teacher (outside of school, if currently taking):
Lesson rates will be $20 per half-hour lesson and $35 per hour lesson.
State Why You Think You Would Be A Good Mentor?
Instructions:
Turn in completed form to Christiana Weiss to schedule training session and level placement. All mentors will require a parent permission and level placement certified by BOEC. Each mentor will also require a bio/resume to have on file, so information may be shared with possible students by request. Wages will be paid to mentor directly unless previously arranged by mentor and parent for BOEC to be the holder of funds.
My child has my permission to participate as a mentor through the BOEC Mentorship Program. Parent's Signature:
Parent's Name Printed:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
THIS IS AN APPLICATION AND NOT A GUARANTEE OF ACCEPTANCE
Should be Empty:

MENTOR (1 on1) MUSIC LESSONS APPLICATION OF INTEREST