Education Scholar Program Registration Form

Please fill in the information below to start the registration process for the Education Scholar Course. When complete, use the “Submit” button at the bottom to submit the form. Your organization will then contact you to complete payment information and establish the required user name and password to activate the account.
Part 1 - Required Information
Send to:
 
Name Information
First: M.I.:
Last:
Address Information
Address: Apt.:
City: State or
Province:
Postal Code: Country:
Contact Information
Home Phone: Work Phone:
Fax: E-mail
Address:
Professional Information
Degrees or
Certificates:		 Years In
Profession:
School, Institution,
or Affiliation:
Module(s) Selected
Module 1: Developing a Personal Working Philosophy to Guide Teaching/Learning in Health Professions Education Module 4b: Problem-based Learning
Module 2: Facilitating Learning in a Traditional Classroom Setting Module 4c: Learning in the Experiential Setting
Module 3: Improving Outcomes through the Use of Active Learning Strategies Module 5: Assessment of Instructional Effectiveness
Module 4a: Distance Learning Module 6: Promoting Teaching/Learning Excellence in Your Institution

Part 2 - Optional Information
Birth Date
(i.e. 12/31/67):		    
Gender:
Current
Position:
Career Goals:
How would you rate your computer and Internet skills?
How did you hear about this program?

 

You can click here to close this window and return to Education Scholar Web site. However, this form will not be sent unless you use the Submit button above.