<p> Candidate profile</p><p>Name:</p><p>Email:</p><p>Assistant’s Name & Email:</p><p>Specialty:</p><p>Current title: Name/Title of Direct Supervisor:</p><p>Institution:</p><p>Baylor TCH St. Luke’s Other:______</p><p>Memorial Hermann / MD Anderson Methodist UT</p><p>Rationale for application:</p><p>Describe your current administrative & leadership responsibilities :</p><p>What are your goals for participation in this course?</p><p>Please attach your CV to this application.</p><p>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.</p><p>__September 27, 2013 __November 15, 2013 __January 31, 2014 __March 28, 2014</p><p>__October 11, 2013 __November 29, 2013 __February 14, 2014 __April 11, 2014</p><p>__October 25, 2013 __January 17, 2014 __February 28, 2014 __April 25, 2014</p><p>*For successful completion of this course, the participant must attend a minimum of 80 hrs (10 classes) and complete the project as assigned.</p><p>Please sign below</p><p>______</p><p>*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.</p>
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