This is an individual assignment. Based on the feedback offered by the provider, identify the best approach for teaching. Prepare a presentation to accompany the teaching plan and present the information to your community. Select Long-term care facility for delivery of the presentation:
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
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