EmailMe Form - Instructor + Course Application Form

Name *

First Middle Last

Professional Title(s) *

Web Site

Email *

Facebook

Instagram

Twitter

Phone *

### - ### - ####

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Tell us about yourself! What is your favorite herb, formula, or acupuncture point or style, and why?

Who is the person that inspires you the most?

Professional Info

License # *

State issuing License *

Educational Institution for each Professional Degree *

License Expiration Date *

Course Info

Course Title *

Number of Units *

if unsure, please estimate
*note 1 unit = 50 minutes content*

Please choose the best description of your relevant experience in writing this course:

You possess a BA or higher degree from a college/university in the subject material you are teaching and are able to provide written documentation proving this. Please list the degree(s) earned and the name of the educational institution.

You are able to document experience in teaching a similar subject matter within the five years providing the course.

You are able to document experience of at least two years (within the last five years) in the specialized area in which you are teaching. Please provide a written explanation of this experience.

Please describe your education, background, and expertise in teaching the course content *

Please provide a brief course outline of the content covered in each hour of the course *

Please submit a quiz for your course that is between 10-15 questions. The quiz format should be True/False or multiple choice with 5 possible answers labeled A-E, and the correct answer underlined. You may use a combination of T/F and multiple choice. Quizzes may also be emailed to info@grasshoppereducation.com *

Please provide 3-5 course objectives, including how they relate to the scope of acupuncture and nursing practice in California *

If the course is co-authored, please list all authors' names and a brief biography.
*Please email a photo of each author to info@grasshoppereducation.com

Has a licensing board previously approved your course with identical course content? *

Yes

No

if Yes, please fill in 1-4 below

1. The name of the approving board(s)
2. The states in which approved
3. The date the course was last approved
4. Number of CE hours granted