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?*
Tell us about your experience integrating Aquifer content into your local curriculum.*
Tell us strategies you have employed in the past to facilitate the adoption of new educational tools or curricula among your peers.*
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 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 5-6 hours of work per month*
(e.g., reviewing coaching tools, delivering professional development)
- 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.
Email
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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:

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:

Phone

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*

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*

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.