Join TEACH Here! Membership Application Step 1 of 3 33% Name* First Last Role* Faculty Staff Resident/Fellow Student If Student, Resident, or Fellow, what is your anticipated year of graduation?N/A202120222023202420252026Address*Mailing address for Welcome material Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Enter Email Confirm Email HiddenEmail Status Opt-out Email undeliverable Degree* HiddenInstitution* Institution Affiliation*Check all that apply Carilion Clinic Virginia Tech Carilion School of Medicine Fralin Biomedical Research Institute at VTC Radford University Carilion Department* Upload your CV(optional)Accepted file types: pdf, doc, docx, Max. file size: 64 MB.HiddenInactive Member Inactive Active TEACH Level*Membership level you would like to apply for (See Membership level descriptions): Advanced Skilled Emerging Emerging - Associate Affliate Emeritus Posthumous Emeritus HiddenArchived TEACH Level for Emeritus/Affiliate Advanced Skilled Emerging Emerging-Associate HiddenMembership Level ChangePlease list the "from level" to the "to level", the date of the change, and the reason for the change. HiddenSteering Committee Member Yes No HiddenSubcommittee Membership Education Research Faculty Development Journal Club Membership Mentoring Awards and Recognition Teaching Observership Technology & Innovation MentorshipDo you wish to be a mentor or mentee through TEACH? (Check all that apply) Mentor Mentee Teaching Scholarship InformationPlease fill out the information below or type 'See CV' if this information is clearly highlighted on your attached CV. N/A is also appropriate for Emerging level membership.Current main teaching responsibilitiesTeaching scholarshipTeaching presentations, posters, publications, etc.Teaching awards or grantsTeaching interest and expertisePlease list specific areas of teaching interests/expertise (if applicable) Primary Faculty AppointmentWith which institution is your primary faculty appointment? (Check all that apply) Carilion Clinic Virginia Tech Carilion School of Medicine Fralin Biomedical Research Institute at VTC Radford University Carilion Faculty Development*Are you 1. interested in, 2. willing, 3. able to contributing to/presenting faculty development relating to teaching as a part of TEACH? Yes No Major Educational Role*Which of the following major educational role(s) do you hold? Residency or Fellowship Program Director or Associate Program Director VTC Dean (Senior, Associate, etc) VTC Block Director VTC Clerkship Director Radford University Carilion Program Director Other educational leadership role. Please describe. Describe Educational Role*Teaching HighlightsAny other teaching highlights that you think would be important to your TEACH application.HiddenJoin TEACH List-serveWould you like to join the TEACH list-serve to receive scholarship and funding opportunities? Yes UntitledFirst ChoiceSecond ChoiceThird Choice
