The University of Tennessee Health Science Center

Tennessee Public Health Workforce Development Consortium

Continuing Education Certificate Program Enrollment Form

Please complete the enrollment form.

General Information

Social Security Number
Last Name		First Name
Current Street Address
City
State/Province		Zip Code + 4
Permanent Street Address
City
State/Province		Zip Code + 4
Day Phone		Evening Phone
E-mail address
Date of Birth	Month January February March April May June July August September October November December           Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31      Year (yyyy)
Country of Citizenship
State of Residency
Highest Level of Education	Highest Educational Level Bachelors Degree (B.S./B.A.) Master's Degree (MS, MPH, MBA, etc) Doctorate Degree (Ph.D., Dr.P.H.) Other Professional (J.D., M.D., etc.) Other
Undergraduate Institution
Undergraduate Degree		Major
Dates Attended	From (mm/yyyy)          To (mm/yyyy)
Graduate Institution
Graduate Degree		Major
Dates Attended	From (mm/yyyy)          To (mm/yyyy)
Organization of Employment
Title
Work Address
City, State, Zip Code

 The U.S. Department of Health and Human Services require that we collect the following information:

Race/Ethnicity American Indian Asian White African American HIspanic/Latino Other                                             Gender Male Female             

Course Schedule 

Courses--Choose a Course Introduction to Epidemiology Introduction to Biostatistics Overview of Public Health Methods of Epidemiology (prereq. req.) Statistical Software for PH Professionals Public Health Leadership Health Care Organizations and Law Health Services Marketing

Vehicle Registration

Complete to obtain UTHSC Parking Permit.  (Please see Parking Services for details about parking on campus.)

Vehicle License No.     State  Vehicle Model 

 

Courses subject to availability.  Registrant will be notified of registration via email.  Course location and other information subject to change without notice.  If you are registering within 5 days of the course start date, call 901-448-5562 to confirm location and availability.  Before you register, please familiarize yourself with our Honor Code (Located under Student Judicial System).  Carefully read, print, and sign the Honor Code Pledge (pdf format), then return it to the Office of Enrollment Services.  Your registration is not complete until the Honor Code Pledge is signed and returned.

After you Submit your application, you will see a page that says "Thank You". If you do not see this page, your application has NOT been forwarded to us.  Please note any error message you get and email to ahall18@utmem.edu.  You should receive email conformation within 2 days that your application was received.  If you don't get confirmation, please email ahall18@utmem.edu.