NRS 427V

Community Teaching Experience

Students must submit this form to the CONHCP Office of Field Experience at [e-mail]

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