BENCHMARK 2
Community Teaching Experience
Students must submit this form as part of the assignment submission.
| Student 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: | |||||||||||
| PowerPoint Presentation | Pamphlet Presentation | Audio Presentation | 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
