Exit this survey

Please take a moment to fill out the Teaching of Tomorrow, 2015-2016 application. Once you fill out the application, you will be hearing from us whether or not you have been accepted into our program for the coming year. As a reminder, you are required to attend BOTH workshop sessions, please check your schedule to make sure you are available to attend both workshop sessions before applying. Workshop dates are November 13-14, 2015 at the Cranwell Resort, Spa and Golf Club in Lenox, MA and March 11-12, 2016 at the Hotel Northampton, Northampton, MA.

* 1. Name:

* 2. Discipline:

* 3. Degree:

* 4. Which TOT course are you interested in? (Track 1 = basic course for new preceptors or Track 2 = advanced course for graduates of Track 1)

* 5. Primary Phone Number:

* 6. Primary Email Address (please note: ALL communication for this workshop series is done via email so please list the email address that you use MOST frequently):

7. Secondary Email Address:

* 8. Academic Affiliation:

* 9. Who referred you for this program?

* 10. Who will be paying for you to attend this workshop series?

* 11. Practice Address/Primary practice site:

12. Mailing address (if different from practice site):

* 13. Age:

* 14. Gender:

* 15. Minority/Disadvantaged Status:
*Underrepresented asian groups include any other than Chinese, Filipino, Thai, Korean, Japanese or Asian Indian.
**Disadvantaged means an individual who 1. comes from an environment that has inhibited the individual from obtaining the knowledge, skill and abilities required to enroll in and graduate from a health professions school, or from a program providing education or training in an allied health profession; or 2. comes from a family with an annual income below a level based on low income thresholds according to family size published by the U.S. Bureau of the Census, adjusted annual for changes in the Consumer Price index, and adjusted by the Secretary for use in all health professions programs (42 CFR 57.1804 c).

* 16. Years in Practice:

* 17. Years in Teaching:

* 18. Student Level(s) Currently Precepted:

* 19. Resident Level(s) Currently Precepted:

* 20. Practice in Underserved Areas (primary practice site):

21. Do you have any dietary restrictions?

* 22. How would you like your name to appear on your CERTIFICATE OF ATTENDANCE and CME CERTIFICATE?

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