Community Teaching Experience

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Community Teaching Experience

Students must submit this form as part of the assignment submission.

image1.jpgStudent Name:__________________

Course Section & Faculty Name:_____________________________

Date of Presentation:_____________

Provider Information

Provider Name :  

 

 

Last First M.I.
Credentials:  

Title:  

(i.e., MS, RN, etc.)
Organization:  

Phone Number:  

E-mail Address:  

Student Presentation Information

Type of Presentation:
FORMCHECKBOX PowerPoint Presentation FORMCHECKBOX Pamphlet Presentation FORMCHECKBOX Audio Presentation FORMCHECKBOX Poster Presentation

D

 

Provider Acknowledgement

I __________________________acknowledge that ____________________________

(Provider Name) (Student Name)

has requested approval to participate in a community teaching experience at the location listed on this form. The organization / agency does not endorse the university or the student however, the teaching plan developed by the student is considered appropriate and of benefit to the community of interest.

______________________________ _________________

Provider Signature Date Signed

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