2018 IPER 4 Faculty Facilitator Registration

Please complete this form to become a faculty facilitator for inteprofessional events.

Name Name * First Last
Email *
Cell Phone Cell Phone * - ### - ### ####
College (Select the college of your primary appointment) *

College (Select the college of your primary appointment) College of Agriculture & Life Sciences College of Dentistry College of Medicine College of Nursing College of Pharmacy School of Public Health Del Mar College Texas A&M University Corpus Christi Texas A&M University Kingsville Other (specify) Other (specify)
Select the location you will be at for the Faculty Facilitator training.
Faculty Responsibilities

1. Facilitate one interprofessional group discussion at IPER 4 event

2. Attend one IPE Facilitation Workshop (Check one box) *

Faculty Responsibilities

1. Facilitate one interprofessional group discussion at IPER 4 event

2. Attend one IPE Facilitation Workshop (Check one box) IPE Facilitation Workshop October 17 (3:00-5:00PM) (In person in Bryan) - CANCELED IPE Facilitation Workshop October 25 (3:00-5:00PM) (Webex Session)
By signing and submitting this form, I am agreeing to do the following:
1. Attend an IPE Facilitation Workshop on either October 17 or October 25; AND
2. Facilitate an IPER 4 student discussion on Thursday, November 1 *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.