Announcing the Center for Advancing Learning and Teaching

Application Form
2009 Institute for Teaching and Learning in the Health Professions

Deadline for Application: April 30, 2009

Full Name:
Preferred First or Nickname:
School or Institution Affiliation (if any):
Title/Academic Rank (if any):
Mailing Address:
City:
State (if USA):
Country:
Zip Code:
Email Address:
Work Telephone:
Home or Cell Phone:
Fax Number:
Invoice Institution for Tuition (if applicable):
If yes, please identify recipient of invoice:
Are you applying for a scholarship award through one of the following organizations?
List undergraduate school attended, major, and degree obtained if applicable:
Please list professional degree(s), including postgraduate education and specialty or area of concentration, and the school from which you received your degree(s).
If you currrently hold an academic position, please indicate if your appointment is :
If you currently hold an academic position, please indicate the courses you teach:
How did you learn about the Center for Advancing Learning and Teaching?
 
Agreement to Participate:

I understand that if I am selected to participate in the ITL, I am required to attend all activities and complete all assignments throughout the Center's two phases. I understand that, once I am accepted, the tuition fee of $4,950 is due within 30 days of receiving acceptance into the program. Failure to submit the tuition by the deadline will result in the loss of my position in the Center. After June 30, 2009, withdrawal from the ITL for any reason will result in the forfeiture of 50% of the tuition. I also understand that the conduct of this program is contingent upon adequate enrollment and factors beyond the control of the Academy for Academic Leadership. Should the program be cancelled for any reason, I will receive a full refund of any tuition paid to the Academy for Academic Leadership. The Academy for Academic Leadership is not responsible for other costs that I incur as a participant in the program. I understand that the Academy for Academic Leadership is not a placement agency and makes no promise of employment as a result of participation in the ITL. My typed or signed name and submission of this form constitutes my Agreement to Participate.

Signature:
Date:
   

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