Candidate Profile Name: Email: Assistant S Name & Email: Specialty: Current Title: Name/Title
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Candidate profile
Name:
Email:
Assistant’s Name & Email:
Specialty:
Current title: Name/Title of Direct Supervisor:
Institution:
Baylor TCH St. Luke’s Other:______
Memorial Hermann / MD Anderson Methodist UT
Rationale for application:
Describe your current administrative & leadership responsibilities :
What are your goals for participation in this course?
Please attach your CV to this application.
Proposed Class Dates for 2013-2014 Please note any dates you would not be able to attend. All classes are on Friday from 8:00am- 4pm.
__September 27, 2013 __November 15, 2013 __January 31, 2014 __March 28, 2014
__October 11, 2013 __November 29, 2013 __February 14, 2014 __April 11, 2014
__October 25, 2013 __January 17, 2014 __February 28, 2014 __April 25, 2014
*For successful completion of this course, the participant must attend a minimum of 80 hrs (10 classes) and complete the project as assigned.
Please sign below
______
*Class dates are subject to change. Please return completed form to [email protected] or UT School of Public Health, 1200 Herman Pressler, RAS W342, Houston, TX 77030.