Faculty Affiliate Interest Form

Name

Title

Organization Affiliation

Email Address

Phone Number

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 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

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