Community Teacher Volunteer Application 2022-23
Thank you so much for your interest in serving as a Community Teacher volunteer!

The 1Health curriculum teaches health profession students the skills necessary to build successful careers in patient-centered, team-based care. Volunteers like YOU are needed to share your real life experience in health care to help students understand how each profession is a valuable member of a health care team!

To apply to become a Community Teacher volunteer, please complete all of the required fields of this form.
Once we receive your completed form, we will be in touch to confirm your participation and provide additional program information. *Please note: All information submitted on this form will be kept on file by the 1Health team within the Academic Health Sciences at the University of Minnesota and will not be shared with outside parties*

All Community Teacher volunteers must meet these minimum requirements:
1) Be 18 years of age or older;
2) Be available to meet virtually (phone or video call) with a team of 3-5 students, three times per program year;
3) Have at least one chronic medical condition requiring medication;
4) Be willing to share with the students their perspective and experience navigating the health care system with regards to their chronic condition.


Feel free to forward the link to this form to any of your family or friends who may be interested in this opportunity as well!

Questions? Contact us by email at cteacher@umn.edu or by phone at 612-626-0575.

Thank you for your consideration and we look forward to hearing from you soon!
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First Name *
Last Name *
Preferred Name
Street Address (include apartment number too, if applicable) *
City *
State (abbreviated) *
Zip Code *
Building Name (if applicable)
Preferred Phone Number *
Secondary Phone Number
Email Address
Date of Birth *
Gender
What is your PREFERRED method of conducting virtual visits? (Due to the challenges that we all are facing because of COVID-19, we want to make sure we are taking measures to ensure the safety of the University community, students, and Community Teacher Volunteers. We have made the decision to suspend in-person visits between students and Community Teacher Volunteers for the entire 2022-2023 academic year. In place of in-person visits, we are asking Community Teachers to be available to meet with students virtually by phone or video call). *
Do you take at least one medication (prescription, over-the-counter, supplement, etc.) every day? *
If yes, how many different prescriptions do you take every day?
Do you have at least one chronic medical condition? *
If yes, please describe:
Do you have any special needs (use of special equipment, mobility issues, language needs, etc.)?
Tell us a little about yourself (family, career, education, volunteering, interests, etc.):
Are you interested in taking on more than one team of students?
Clear selection
How did you hear about us? *
Required
If you answered "Other" to the above question, how did you hear about us?
Emergency contact first and last name *
Emergency contact relationship to you *
Does this person live with you?
Clear selection
Emergency contact primary phone *
Emergency contact secondary phone
Emergency contact email address
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