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

FALL APPLICATION DEADLINE: February 21, 2014

Personal Information

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

 NoneBasicIntermediateAdvanced
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Geographic Information System
Survey Design and Implementation
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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

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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

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