NRS427 Concepts in Community and Public Health

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

Student Success Center