Humanism and Excellence in Teaching Award Application Form


School Name

Street Address

City, State, Zip

Faculty Mentor

Mentor Title & Department

Telephone

Fax Number

E-mail Address

Proposed Date for Student Clinician's Ceremony (YYYY-MM-DD)

Name and Title of Dean to Sign Certificate

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


Resident Name

Department

Address


Resident Name

Department

Address


Resident Name

Department

Address


Resident Name

Department

Address


Resident Name

Department

Address