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…
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