Children’s of Alabama

Continuing Education Instructor Information

Complete yearly or with changes in education, work, or teaching experiences.

Section 1: Demographic Data

Name with Credentials/Degrees:

License Number:	Type: Expiration Date:

Section 2: Education

Degree/Certification	College/University/Organization	Major	Year Awarded

Section 3: Professional Experience/Area of Expertise

Briefly describe your professional experience and area(s) of expertise.

List your teaching experience:

An “X” in the box below serves as the electronic signature and attests to the accuracy of the information given above.

☐ Name and Credentials Required):	Date: