City, State, Zip
Mentor Title & Department
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?
Is there a joint 2nd/3rd year student working group?
Do you display a poster of award winners?
Do you hold a reception following the SCC?
Do you give a gift to the rising 3rd years?
If so, what?
Describe any additional components of your school's SCC which might be of interest to other schools.