Community Health Leadership Program Online Certificate Application

FALL APPLICATION DEADLINE: February 21, 2014

Personal Information

Last Name *

First Name *

Middle Name

Suffix (Jr., III)

Gender *

Female

Male

Date of Birth (mm/dd/yyyy) *

Country of Birth *

Active Email Address

Carefully enter your primary email address that will remain active throughout the application process.
We communicate by email only, so be sure to monitor this email account often.
Also check to be certain that any SPAM blockers include "@msm.edu" as acceptable or include this on your WHITE list.

*

Personal Email Address (gmail, yahoo or hotmail) *

Alternate email address (school or work)

Applicant

Select one of the following to reflect your U.S. citizenship status. *

NOTE: The ethnicity options provided here conform to current federal and state guidelines governing ethnicity reporting. Under the new guidelines, applicants are to provide this information in a set of two questions.

1. Ethnicity: Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race) *

2. Race: Select one or more that apply *

Please enter the last four digits of your Social Security Number (###-##-____)

Date Greed Card issued

Georgia Residency Information

International applicants who are permanent residents of the United States (i.e., permanent resident alien status) can apply as a Georgia resident for tuition purposes if they meet the eligibility requirements. United States Citizenship is required for acceptance into the program.

All applicants who claim to be Georgia legal residents for tuition purposes will be required to submit a Residency Status Form with their application.

Georgia Residency *

Permanent Phone Number
###-###-#### *

Home Phone Number
###-###-####

Work Phone Number
###-###-####

Mobile Phone Number
###-###-####

Current Address Information

Address 1 *

Address 2

City *

State (U.S. only) *

Province (Canada only)

Postal Code *

Country *

IF ACCEPTED INTO THE PROGRAM, DO YOU HAVE PERSONAL TRANSPORTATION?* *

Current Educational History

Degree *

Degree history, if applicable:
I have earned my Bachelor’s Degree (or international equivalent) *

Institution Name

Degree Received

Course of Study

Entered Bachelor's Program

Month

Year

Received Bachelor's Program

Month

Year

My transcript corresponding to my Bachelor’s (or international equivalent) degree is attached to this application as an electronic file.

Attach electronic copy of your Bachelor’s Degree (or international equivalent) transcript here as either a .PDF or .JPG or .DOC file.

REMINDER: Obtain and send transcript to Course Instructor if you do not attach an electronic copy to this application.

Upload Transcript

Current Educational Status

I am currenlty enrolled in a degree program *

I would be interested in earning a Master's of Public Health in the Public Health Program at Morehouse School of Medicine in the future. *

Have you been accepted into any graduate study programs? *

Do you have any computer skills? *

	None	Basic	Intermediate	Advanced
Word	None	Basic	Intermediate	Advanced
WordPerfect	None	Basic	Intermediate	Advanced
Excel	None	Basic	Intermediate	Advanced
Lotus 123	None	Basic	Intermediate	Advanced
Access	None	Basic	Intermediate	Advanced
SPSS/SAS	None	Basic	Intermediate	Advanced
PowerPoint	None	Basic	Intermediate	Advanced
Social Media (FB, Twitter, etc.)	None	Basic	Intermediate	Advanced
Geographic Information System	None	Basic	Intermediate	Advanced
Survey Design and Implementation	None	Basic	Intermediate	Advanced
Adobe Professional	None	Basic	Intermediate	Advanced
Other	None	Basic	Intermediate	Advanced

Language Proficiency

Is English your first language? *

What is your first language?

Academic Awards, Honors, Scholarships and Fellowships Earned. Indicate any special recognition you have received:

0/500 characters

Work Experience

Beginning with your current work experience, please list employment, volunteer work, military service, etc.

Job Title

Employer

Enter Start Date - End Date

Roles/Responsibilities

Job Title

Employer

Enter Start Date - End Date

Roles/Responsibilities

Job Title

Employer

Enter Start Date - End Date

Roles/Responsibilities

Job Title

Employer

Enter Start Date - End Date

Roles/Responsibilities

Attach electronic copy of your degree transcript here as either a .PDF or .JPG or .DOC file.

REMINDER: Send resume to Course Instructor if you do not attach an electronic copy to this application.

Upload Resume

My resume is attached to this application as an electronic file. *

Supervisor/Employer Recommendation Letter

Professor Recommendation Letter

Community Involvement Interest/Experience:

Please explain your community involvement interest (your response is limited to 300 words maximum).

0/300 words

Please explain any leadership roles/positions you have held (your response is limited to 300 words maximum.)

0/300 words

Personal Statement: Use of the Knowledge Gained from this Certificate

Please explain how you would use the knowledge gained from this certificate (this response field is limited to 300 words, but space is provided below to complete your response.)

0/300 words

Personal Statement: Your Resources to Complete this Certificate

Please describe your resources available to complete this certificate, including time to allocate to completing the certificate, technical and financial requirements. (This response field is limited to 300 words, but space is provided below to complete your response.)

0/300 words

Morehouse School of Medicine Community Standards

In an effort to maintain a safe learning community, we must ask the following questions of all applicants. We cannot accept your application unless you answer these questions and provide the required documentation. Your "yes" answer to one or more of the following questions will not necessarily preclude your being admitted. However, your failure to provide complete, accurate, and truthful information will be grounds to deny or withdraw your admission, or to dismiss you after enrollment. For the purpose of the following questions, "crime" or "criminal charge" refers to any crime other than a traffic-related misdemeanor or an infraction. You must, however, include alcohol, drug or sexual offenses related to criminal charges.

If you answer "yes" to any of the questions below, you are required to provide your own written explanation of the event and a statement from your legal representative summarizing the event(s) and the final disposition of your case. If additional information is needed, you may be asked to submit information for a criminal background check, including a nominal fee. *

I have read and comply with this statement

Have you ever been convicted of a crime? *

Please use the space below to explain your conviction of a crime.

0/300 words

Have you entered a plea of guilty, a plea or no contest, a plea of nolo contendere, or an Alford plea, or have you received a deferred prosecution or prayer for judgment continued, to a criminal charge? *

Please use the space below to explain your plea.

0/300 words

Have you otherwise accepted responsibility for the commission of a crime? *

Please use the space below to explain your acceptance of responsibility of a crime.

0/300 words

Do you have any criminal charges pending against you? *

Please use the space below to explain your pending criminal charges.

0/300 words

Have you ever been dismissed, suspended, expelled, placed on probation, other otherwise subject to any disciplinary sanction by any school, college, or university? This can include, but is not limited to, academic cheating, conduct violations, or alcohol policy infractions. *

Please use the space below to explain any disciplinary sanction by any school, college, or university.

0/300 words

Additional Information

Attach electronic copy of the school's official statement here as either a .PDF or .JPG or .DOC file.

Attached is an electronic copy of the statement from an appropriate school official corroborating your summary of events. *

IMPORTANT: If you answered "yes", in addition to your own explanation, you are required to provide a statement from an appropriate school official corroborating your summary of events.

REMINDER: If you did not attach an electronic copy of the school's statement, then you or the school should provide their statement to Course Instructor if you do not attach an electronic copy to this application.

Have you ever served in the military? *

Did you receive any type of discharge other than an honorable discharge from the military? *

Please use the space below to explain your military discharge.

0/300 words

Additional Information

You must promptly notify The Satcher Health Leadership Institute in writing of any criminal charge, any disposition of a criminal charge, or any school, college, or university disciplinary action against you, or any type of military discharge other than an honorable discharge, or any non-routine absence from school that occurs at any time after you submit this application. Your failure to do so will be grounds to deny or withdraw your admission, or to dismiss you after enrollment. *

I have read and comply with this statement

Applicant Signature

I certify that the information provided herein is complete and accurate. I authorize the Satcher Health Leadership Institute and Morehouse School of Medicine to make reasonable inquiry if any doubt should arise, and I understand that falsifying or withholding information in completing this application constitutes grounds for immediate withdrawal of my application from further consideration and cancellation of my admission or registration. To sign the above statement, type your full name: *

Enter date signed *

IMPORTANT: All hard copy materials must be provided to the Course Instructor on or before February 21, 2014. Please direct these to:

Dr. Toyosi Adekeye
Director, Community Health Leadership Program
Division of Health Promotion and Disease Prevention
Satcher Health Leadership Institute
NCPC 206
Morehouse School of Medicine
720 Westview Dr. SW
Atlanta, GA 30310
Office: 404-756-1278
Email: oadekeye@msm.edu