Community Affiliate Interest Form

Name

Title

Organization Affiliation

Email Address

Phone Number

Are you established in an urban or rural community? Are you established in an urban or rural community?UrbanRural (RUCC 4-9)

If located in rural community, what county are you located?

Background - Please describe your background as it pertains to nursing/rural health care:

Expertise - Please describe your level of experience in the nursing/rural health care field:

Would you be interested in partnering with nearby rural communities on research studies/evaluations/pilot programs? Would you be interested in partnering with nearby rural communities on research studies/evaluations/pilot programs? No Yes Other, I would need more information

Would you be interested in attending/presenting in the Center's Seminar Series held monthly? Would you be interested in attending/presenting in the Center's Seminar Series held monthly? No Yes, attend Yes, present Yes, both/either Maybe

Would you be interested in attending/presenting in the Center's Rural Health Conference held yearly? Would you be interested in attending/presenting in the Center's Rural Health Conference held yearly? No Yes, attend Yes, present Yes, both/either Maybe

Would you be interested in attending/presenting at other events hosted by the Center for Rural Health and Nursing? Would you be interested in attending/presenting at other events hosted by the Center for Rural Health and Nursing? No Yes, attend Yes, present Yes, both/either Maybe