sather health leadership institute community health leadership progam application
Community Health Leadership Program Online Certificate Application

FALL APPLICATION DEADLINE: February 21, 2014

Personal Information

* Gender

Applicant

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.

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.


Current Address Information


Current Educational History

Entered Bachelor's Program
Received Bachelor's Program
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.




 

Current Educational Status

* Do you have any computer skills?
 NoneBasicIntermediateAdvanced
Word
WordPerfect
Excel
Lotus 123
Access
SPSS/SAS
PowerPoint
Social Media (FB, Twitter, etc.)
Geographic Information System
Survey Design and Implementation
Adobe Professional
Other

Language Proficiency

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Work Experience

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


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.



 

 

 

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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.
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Additional Information

 
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.



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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.

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

* Indicates Response Required