18 Jan Pamphlet Presentation

NRS427 Concepts in Community and Public Health

Week 5 Assignment

Community Teaching Experience Approval Form

Before presenting your “Community Teaching Plan: Community Presentation” to the community, seek approval from an agency administrator or representative. Upon receiving approval from the agency, submit the completed “Community Teaching Experience Approval Form.”

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