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The Physicians Committee



Translating Nutrition Research into Community Education

A Workshop for Implementing Diet-Related Chronic Disease Curricula

Instructor Application Form

Contact Information

First name MI Last name
Other name(s)?
Address City State Zip
Home phone Mobile Fax
Email

Requirements

Each class in the Food for Life series requires marketing and promotion, plus a total of five to six hours for shopping, food preparation, conducting the two-hour class, pre- and post-class paperwork, and clean up. Can you make such a time commitment?

Do you have a car (recommended)?

Do you have an e-mail address and access to the Internet?

If accepted as an instructor, you will be required to attend a fee-based, three-day training in Washington, D.C. The training fee must be paid in full within three weeks of receipt of the acceptance letter. All travel and accommodation expenses are covered by the candidate.
Can you commit to attend this training?

In order to be considered, this application must be returned with a short video (less than five minutes) of yourself doing a cooking demonstration. The video can be homemade and can be a staged cooking class attended by family and friends. The video must be submitted via YouTube or website link and must be submitted with your completed application. No CDs, DVDs, or video cassettes.

Expression of Interest

Have you previously applied to be a cooking instructor with PCRM’s Food for Life program? If so, provide all pertinent details. Please describe, concisely, why you are interested in teaching PCRM’s Food for Life program.

Current Employment

Professional Background

Please note any nutrition or health-related degrees, certifications, professional designations, licenses, etc. (see examples below) along with the name of the issuing entity, the state/jurisdiction of issuance, the date the license/certification was first obtained, and any identification numbers or expiration dates. Examples: R.D., Nurse Professional, M.D., D.O.

Please describe any additional nutrition cooking or teaching/presentation related experience.

Please describe your plan for teaching the FFL classes in your community. Where, When, How many classes will you teach?

How do you plan to promote the FFL classes that you teach to secure venue hosts and participants?

Professional Background, cont.

Please describe any marketing and business/entrepreneurial experience you have.

The nutrition information and foods provided in the Food for Life classes are plant-based (whole grains, legumes, vegetables, and fruit). Please describe your opinion of a low-fat diet that does not include animal products as it relates to health.

Do you currently follow a vegan diet? Please describe your diet.

The Food for Life program is designed to educate the average consumer about plant-based diets and health. It is not designed to address issues such as organic farming, GMOs, local/seasonal eating, raw foods, animal rights, the environment, or other areas of personal interest to instructors. Can you adhere to this standard?

Have you ever been terminated from or resigned from a clinical or professional training program? If so, provide all pertinent details.

Have you ever withdrawn or had rejected an application to practice your profession? If so, provide all pertinent details.

Has your professional license ever been suspended or revoked? If so, provide all pertinent details.

Have you ever voluntarily surrendered a license or privileges after formal charges have been filed against you or while under nvestigation? If so, provide all pertinent details.

Have you ever been party to a malpractice action or had a malpractice action brought against you? If so, provide all pertinent details.

Have you ever been terminated from employment due to practice issues? If so, provide all pertinent details.

Professional References

Professional references need to be supervisory in nature and can include professors and/or volunteer supervisors.

Authorizations

Have you been convicted of a crime other than a minor traffic offense? Yes � No � If yes, list convictions that are a matter of public record. Arrests are not convictions. A conviction will not necessarily disqualify you. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.

Certification

I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that if licensed to teach the Food for Life program, falsified statements on this form shall be grounds for termination of the licensing agreement. I authorize investigation of all statements contained herein and release all parties from all liability for any and all damage that may result from utilization of such information. Signature Date IF FILLING OUT ELECTRONICALLY, YOUR PRINTED NAME WILL SERVE AS A SIGNATURE
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The Physicians Committee
5100 Wisconsin Ave., N.W., Ste.400, Washington DC, 20016
Phone: 202-686-2210     Email: pcrm@pcrm.org