COUNCIL ON COMMUNICATIONS AND MEDIA
2009 MEDIA VISITING PROFESSORSHIP APPLICATION FORM

Name and address of Applicant Institution:
Name:
Address:
City, State, Zip:
Country:
Contact information for individual completing application:
Name:
Phone:
Fax:
Email:

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Total number of Pediatric Residents:
Total number of Medicine/Pediatric Residents:   (not included in previous amount)

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Department Chairperson:
Name:
Address:
City, State, Zip:
Country:
Phone:
Email:

Program Director:
Name:
Address:
City, State, Zip:
Country:
Phone:
Email:

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Statement of educational needs to be met by the visiting professor.

Are there specific media-related topics that you are particularly interested in? Examples include: general overview, media violence, sex & media, drugs, obesity & eating disorders, advertising, and media training.

Describe any existing research in, or teaching about, media within your institution or community.

Anticipated format of the visit. Please provide a complete and detailed program schedule.

Deadline for receipt of application is September 1, 2008.