Clinical Faculty Academy- Participant Registration

1.Session(Required.)
2.Name(Required.)
3.Email(Required.)
4.Cell Phone (only used to contact in case of emergency)(Required.)
5.Institution or Hospital Affiliation(Required.)
6.Job Title(Required.)
7.Please select your highest level of education.(Required.)
8.Do you have any previous teaching experience?(Required.)
9.How did you hear about the Clinical Faculty Academy?(Required.)
10.Commitment Statement: I understand that there is no fee to participate in the Clinical Faculty Academy. However, I am committing to attendance for both days of the training.(Required.)
11.Lunch will be provided by a sponsor both training days. If you have any food allergies or dietetic restrictions, please be prepared to bring your own lunch.(Required.)