Benchmark 1
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