AR-GEMS Application

(* = Required)

Personal Information:

Name:
 *
Current position/Title:
 *
Current employer:
 *
Preferred mailing address:
 *
City:
*
State:
*
Zip:
 *
   
Home address:
City:
State:
Zip:
   
Work phone:
*
Home phone:
 *
Fax number:
Email address:
 *

Discipline: *

Allopathic Medicine Occupational Therapy
Art Therapy Optometry
Audiology Pharmacy
Consumer & Family Services Physical Therapy
Counseling Physician's Assistant
Dental Hygiene Podiatry
Dentistry Psychology
Dietetics/Nutrition Public Health
Gerontology Recreational Therapy
Health Education Respiratory Therapy
Kinesiology Social Work
Medicine: Sociology
Nursing Speech Pathology
    Other:

 

Education: *
Please include Institution/Location, Major, Degree and Year conferred

Professional Experience: *
Please list in reverse chronological order, giving dates, titles and employers:


Please respond to these questions:

  1. What do you expect to learn from participating in the AR-GEMS program? *

  2. How do you expect to apply training received in the AR-GEMS program to future work? *

  3. Specifically, reference plans to your work in rural areas and/ or with community teaching teams. *

 

The information requested below is required by our funding agency. It will be used only to prepare the progress report submitted to the Bureau of Health Professions annually for GEC work completed. Thank you.
--The staff of the Arkansas Geriatric Education Center

Gender: * Male Female

Ethnic background:
Please check one in the list below:

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Non-resident alien international