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The Physicians Committee



Food for Life: The Power of Food for Health

Translating Nutrition Research into Community Education

A Workshop for Implementing Diet-Related Chronic Disease Curricula

Instructor Application Form

Contact Information

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 URL and must be submitted with your completed application. No CDs, DVDs, or video cassettes.

Expression of Interest

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?

Current Employment

Do not exclude any employment. Include temporary and/or U.S. Military service.

May we contact this employer?

Add Employer

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 any marketing and business/entrepreneurial experience you have.

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 investigation? 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.

Teaching Objective

Please describe your plan for teaching the FFL classes in your community. For example, where and when will you teach, and 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 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?

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