Assignment 5 A2

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