FCM 170.14 Clinical Skills Training Session Sign-Up

Please complete the form below ONLY if enrolled in the FCM 170.14 Hepatitis B: Clinical Skills elective (must concurrently be enrolled in FCM 170.13: Hepatitis B: Community Outreach and Education).

Please remember your requirements for the Fall 2009 quarter: you MUST attend 2 training sessions (sign-up using this form) by the end of the Fall 2009 quarter, and 2 clinics (either at Mt. Zion on every 1st Saturday of each month or CPHC in Chinatown on the 2nd Saturday of each month) by the end of the 2009-2010 academic year (end of Spring Quarter).

* Required

First Name *

Last Name *

School *

Year *

Email Address *

Training Session - 1st Choice * All training sessions are from 5:30-7:30 PM

Training Session - 2nd Choice * All training sessions are from 5:30-7:30 PM

Training Session - 3rd Choice * All training sessions are from 5:30-7:30 PM

Training Session - 4th Choice * All training sessions are from 5:30-7:30 PM

Training Session - 5th Choice * All training sessions are from 5:30-7:30 PM

Clinic Volunteer - 1st Choice * All clinics are on Saturday mornings, from about 7:30 AM - 1:00 PM - MUST have 2 training sessions completed before volunteering!

Clinic Volunteer - 2nd Choice * All clinics are on Saturday mornings, from about 7:30 AM - 1:00 PM - MUST have 2 training sessions completed before volunteering!

Clinic Volunteer - 3rd Choice * All clinics are on Saturday mornings, from about 7:30 AM - 1:00 PM - MUST have 2 training sessions completed before volunteering!

Clinic Volunteer - 4th Choice * All clinics are on Saturday mornings, from about 7:30 AM - 1:00 PM - MUST have 2 training sessions completed before volunteering!

Clinic Volunteer - 5th Choice * All clinics are on Saturday mornings, from about 7:30 AM - 1:00 PM - MUST have 2 training sessions completed before volunteering!