Aquifer Peer Trainer Application

Name*
First Last
Email*
Enter Email Confirm Email
Institution*
Program Type*
- MD
- DO
- NP
- PA
Current Position/Title*
Discipline/Specialty*
Why are you interested in becoming an Aquifer Peer Trainer?*
How many years of clinical teaching experience do you have, and in what settings? Are you currently teaching?*
Describe your coaching experience coaching students (e.g., learner levels, purpose of the coaching). What did you find rewarding? What did you find particularly challenging? How did you work to improve your skills?*
Describe your experience delivering faculty development to your peers. What do you enjoy the most? What do you feel are your strengths?*
Describe your experience using Aquifer cases and/or assessments with students.*
I am able to attend a required orientation session on one of the following days*
Choose one
- June 9, 2022 3:00-5:00 p.m. EST
- June 16, 2022 3:00-5:00 p.m. EST
I am able to attend the monthly virtual meeting*
Occurs third Thursday of the month at 3:00 p.m. EST
- Yes
- No
I am able to do an average of 3-4 hours of work per month*
(e.g., reviewing coaching tools, delivering professional development for pilot programs)
- Yes
- No
Are you an active member of an Aquifer collaborating organization?*
Choose any/all that apply
- AAIM/CDIM
- AGS
- AMSER
- COMSEP
- PAEA
- STFM
- AACOM
- None
Please upload your CV*
Acceptable formats: .pdf, .doc, .docx
Accepted file types: pdf, doc, docx, Max. file size: 256 MB.
Comments
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"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

Name

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

Comments

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

Comments

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

Name

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*