Preceptor Qualification Form

This form is for new preceptors to fill out prior to taking their first student. Returning preceptors should complete the Physician Update Form.

Identification
Practice Information
Please select the options that reflect your practice.
What percentage of your practice is?
2019 Availability
Please fill out the fields below indicating your availability for 2019 preceptorships.
I hereby give the Texas Pediatric Society, the Texas Chapter of the Academy of Pediatrics, its successors and assigns those acting under its permission or upon its authority, the unqualified right and permission to reproduce, copyright, publish, circulate, or otherwise use my name/or photographic likeness of me still, single, multiple or moving in which I may be included in whole or in part, or composite. I waive any right to inspect or approve the finished product, products, or copy that may be used or the use to which it may be applied. This authorization and release covers the use of said materials in any published or broadcast form, and any medium of advertising, publicity, or trade in any part of the world for any unlimited period of time. Furthermore, for the consideration above mentioned, I, myself, heirs, executors, administrators, or assigns, transfer to the organization, its successors and assigns, all of my rights, title, and interests in and to all reproductions taken of me by representatives or the organization. This agreement represents in full all terms and considerations and no other inducements, statements, or promises have been made to me.