Are you an Apprenticeship in Teaching Program participant? Yes No
Where will your videotaped teaching practice take place? On-campus Off-campus
Please provide the exact on campus location where you will be teaching (e.g. ICC 223; New North 305)
Please provide the exact name and address of the institution where you will be teaching:
Are you the instructor of the course that you are asking to have videotaped? Yes No
Are you the teaching assistant in the course that you are asking to have videotaped? Yes No
Is this a discussion section of a lecture that you are TA-ing for? Yes No
Are you a student in this course? Yes No
Please provide the name of the course (e.g. General Psychology or The Ethnographic Imagination):
Please provide the course ID of the course (e.g. HIST-150-01.Spring2008):
How many students are in your class?
Are there any students under the age of 18? Yes No
When does the course meet? (e.g. MWF 10:15 - 11:30 a.m.; TR 12:00 - 12:50 p.m.)
Please suggest a date when you would like your session to be videotaped:
Please suggest an alternate date when you would like your session to be videotaped:
Please download this release form and ask everyone who will be present during your session to sign it. Please keep in mind that each person has a right to refuse signing the form, in which case we will ask the person to sit in a location in the classroom where they will be off-camera.
AT Program Video Release Form
Questions, comments, and other information: