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Humanism and Excellence in Teaching Award Application Form
School's Name
Street Address

City, State, Zip City: State: Zip:
Faculty Mentor
Mentor Title & Department
Telephone Area Code   Number
Fax Number Area Code   Number
E-mail Address
Proposed Date for Student Clinician's Ceremony:
Name and Title of Dean to Sign Certificate: Name:
Title:
How many years has your school been holding an SCC?
Number of Students in Class:
Do you recite/discuss an oath? yes    no  
Is there a joint 2nd/3rd year student working group? yes    no
Do you display a poster of award winners? yes    no
Do you hold a reception following the SCC? yes    no
Do you give a gift to the rising 3rd years? yes    no
If so, what?
Additional Components Describe any additional components of your school's SCC which might be of interest to other schools.
Award Winners
print names as they should appear on certificate
Resident Name Department Address
1.

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  E-mail Address:    
2.

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  E-mail Address:     >
3.

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  E-mail Address:    
4.

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  E-mail Address:    
5.

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  E-mail Address:    
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  E-mail Address:    
  


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