Get Involved! Form Please complete the following Get Involved! Form indicating how you would like to help in the OHSU PA Program. Name: E-mail: Practice Specialty: Practice Name: Practice Address: Practice City: Practice State: Practice Zipcode: Practice Phone Number: Home Phone Number: Cell Phone Number: I am interested in supporting the PA Program by: Mentoring a first year student Precepting a second year student Serving on a committee Giving a lecture Helping with physical examination class or lab Proctoring clinical examinations Becoming a small group facilitator If you checked lecture above, which topic areas?: If you checked serve on a committee, which one?: Admissions Committee Curriculum Committee Progress & Promotions Committee Additional Comments: What is the best way to contact you?: Email Work Phone Home Phone Cell Phone