2021-2022 Resident Teaching Pharmacy Education Contact Info Form

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First Name *

Preferred first name if different:

Last Name *

Preferred Email *

UW email: (Required for use of UW resources like the course site and online library access - procedure outlined here: https://sop.washington.edu/about/office-of-the-dean/clinical-affiliate-faculty/ )

Please indicate which program you are registering for: (please note that payment will be at https://washington.irisregistration.com/Form/4828 ) *

Introduction to Teaching, Workshops I and II; Fee = $175.00 (please make sure to go to the separate payment form)

Teaching Certificate in Pharmacy Education (TCPE), Workshops I - VI; Fee = $350.00 (please make sure to go to the separate payment form)

Precepting Training only

Pharmacy residency program currently enrolled in: *

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