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* 1. Session

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* 2. Name

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* 3. Email

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* 4. Cell Phone (only used to contact in case of emergency)

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* 5. Institution or Hospital Affiliation

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* 6. Job Title

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* 7. Please select your highest level of education.

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* 8. Do you have any previous teaching experience?

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* 9. How did you hear about the Clinical Faculty Academy?

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* 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.

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* 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.

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