Zero Balancing Certification Program

Zero Balancing Certification Program

Candidate/Mentor Tracking Form

Candidate Name: ___________________________ Mentor Name: __________________________

A. ZB Sessions Given: (50 required)

Please write date and initials of recipient.

1. Date: _____________ Initials: ________

2. Date: _____________ Initials: ________

3. Date: _____________ Initials: ________

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B. ZB Sessions Received: (10 required)

Please write date and initials of Zero Balancer (does not have to be a certified Zero Balancer.)

1. Date: _____________ Initials: ________

2. Date: _____________ Initials: ________

3. Date: _____________ Initials: ________

4. Date: _____________ Initials: ________

5. Date: _____________ Initials: ________

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C. Touch Feedback tutorials with ZB mentor/ faculty: (2 required)

Please write name of your mentor, and the ZB teacher, date and have them initial the entry:

1. Zero Balancer: ________________________

Date: ___________ Initials: _______

2. Zero Balancer: ________________________

Date: ___________ Initials: _______

D. ZB Sessions Observed: (2 required)

Please write date and initials of Zero Balancer.

1. Date: _____________ Initials: ________

2. Date: _____________ Initials: ________

E. ZB Sessions given/received to/from Certified Zero Balancers: (4 given, 4 received required)

Write name, date and have Zero Balancer initial.

Sessions given:

1. Name: __________________________

Date: _____________ Initials: ________

2. Name: __________________________

Date: _____________ Initials: ________

3. Name: __________________________

Date: _____________ Initials: ________

4. Name: __________________________

Date: _____________ Initials: ________

Sessions received:

1. Name: __________________________

Date: _____________ Initials: ________

2. Name: __________________________

Date: _____________ Initials: ________

3. Name: __________________________

Date: _____________ Initials: ________

4. Name: __________________________

Date: _____________ Initials: ________

F. Papers/Projects: (2 essays or 1 essay & 1 community service project write-up required)

Please send to your mentor for feedback and note dates when sent and when feedback received:

#1. Date Sent to Mentor: _______________

Date Feedback Rec’d: ______________

#2. Date Sent to Mentor: ______________

Date Feedback Rec’d: ______________

G. Written Case Reflections: (50 required)

40 written about ZB sessions given.

2 written about required touch feedback tutorials

8 written about sessions received, additional. tutorials received, sessions observed or sessions given.

Please send written case reflections in batches of 10 to your mentor for feedback and note dates when sent and when feedback received:

#1-10. Date Sent to Mentor: _______________ Date Feedback Rec’d: ______________

#11-20. Date Sent to Mentor: ______________

Date Feedback Rec’d: ______________

#21-30. Date Sent to Mentor: ______________

Date Feedback Rec’d: ______________

#31-40. Date Sent to Mentor: ______________ Date Feedback Rec’d: ______________

#41-50. Date Sent to Mentor: ______________

Date Feedback Rec’d: ______________

G. Final Check-out Evaluations with ZB faculty: (2 required)

When you successfully pass the check-out, please write name of ZB teacher, date and have them initial:

1. ZB Teacher: ________________________

Date: ___________ Initials: _______

2. ZB Teacher: ________________________

Date: ___________ Initials: _______

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