Student Affiliate Interest Form

Name

University Affiliation

Degree Level (Working On) Degree Level (Working On) Doctoral Masters Bachelors Associates High School

Major Field of Study

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 the Center's Seminar Series held monthly? Would you be interested in attending the Center's Seminar Series held monthly? No Yes Maybe, I would need more information

Would you be interested in attending the Center's Rural Health Conference held yearly? Would you be interested in attending the Center's Rural Health Conference held yearly? No Yes Maybe, I would need more information

Would you be interested in attending other events hosted by the Center for Rural Health and Nursing? Would you be interested in attending other events hosted by the Center for Rural Health and Nursing? No Yes Maybe, I would need more information

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

Would you be interested in taking a “Writing for Publication with a Rural Nursing Focus” course? Would you be interested in taking a “Writing for Publication with a Rural Nursing Focus” course? No Yes Other, I would need more information

What resources do you/your organization/community already have available?

What resources do you/your organization/community need? (Please list in order of severity. EX: need new computers/technology)

What are some specific healthcare needs in the community your organization serves (If Applicable)? (Ex: high infant/maternal mortality rates)