Health Professional/Institution Contact Form
Please complete this form to indicate your Facility's and your own interest in participating in community outreach and student engagement activities. Your Responses will help us coordinate effective partnerships and opportunities. this form is intended to collect responses on you or your employers ability to engage with community activities provided by SPCC Atlanta AHE. Please Fill out this information so we can understand your facilities capacity to volunteer health professionals or access to the health facility for Health Education and Health Promotion Purposes. If you do not have authority to approve on site community engagement please still provide your information as there are multiple community engagement opportunities other than a Shadowing or Clinical Training. For Shadowing opportunities please fill out the shadowing Preceptor Agreement MOU. share your contact information for future networking and collaboration opportunities. The information submitted may be used to connect you with community engagement and professional development opportunities, including speaker panels, student shadowing experiences, preceptorships, health facility tours, and program workshops. We value your commitment to advancing health education, health promotion, and health communication across diverse public health issues.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
County
Employer
Job Title
Professional Title
What Community Engagement Opportunity would you like to participate in?
AHEC Scholars
Shadowing w/ High School Students
Shadowing (18+/Undergraduate and up)
Health Facility Tour
Professional Panel Speaker
Pathway to Smiles
Pathway to College (College Representative)
Pathway to College (Mock Interviewer)
All of the Above
Clinical Placement Rotation Site for RN, PA, NP, MD or Dental Students
Submit
Should be Empty: