UNIVERSITY OF UTAH GERONTOLOGY PROGRAM APPLICATION FOR CERTIFICATE PROGRAM
(Please print or type)
Name: ______________________________
Student ID# ____________________
Local Address: ___________________________________________
City/State/Zip: ___________________________________________
Permanent Address: ______________________________________
City/State/Zip: ___________________________________________
Phone (work/home): _____________________________________
E-mail: ___________________________________________________
Affirmative Action: (Optional)
Male: _____ Female: _____
U.S. Citizen: Yes_____ No_____
If no, type of visa: _______________________
Handicapped: Yes_____ No_____
Ethnic Origin:
American Indian or Alaskan Native _____
Asian or Pacific Islander _____
African-American _____
Hispanic _____
Caucasian _____
Other _____
Major: ___________________________________
Birthdate: _________________________________
Level in School: ___Junior ____Senior____Masters ___Doctoral ___ Other (non-matriculated)
Certificate applying for:
_____ Undergraduate
_____ *Graduate
_____ On-Line Undergraduate
_____ *On-Line Graduate
*Graduate certificate applicants must submit documentation of completion of baccalaureate degree. List any honors you have received.
Discuss your education and vocational plans and include reasons for your interest in Gerontology. (please attach additional sheets if necessary).
Discuss briefly any current or past experiences, activities, academic programs, or organizations with which you have been or are presently working with the elderly.
Discuss briefly any current or past experiences working in rural settings and/or working with ethnic minorities.
How did you become aware of the Gerontology Certificate Program?
How long do you expect to take to complete the certificate? ____________ semesters
* Online Certificate Students Only:
Briefly explain how the online certificate best fits your circumstances? In other words, "Why the online certificate...for you?"
Applicant's statement: The above information is accurate to the best of my knowledge. I agree to comply with the prescribed courses as mutually agreed upon by myself and as a representative of the Gerontology Program.
Signature:____________________________________ Date:___________________
Please return this completed form via regular mail along with $ 15.00 processing fee and transcripts to:
University of Utah Gerontology Program
Academic Advisor
10 South 2000 East
Salt Lake City UT 84112-5880
801-581-8198 (phone)
Questions? Email gerontology@nurs.utah.edu or Mirela Rankovic
ATTENTION NON-MATRICULATED STUDENTS
Non-Matriculated Students must complete the Application for Permission To Register as A Non-Matriculated Student and pay the $35.00 ($60.00 late) fee.
Applications for Admissions will be considered late after the following dates*:
Fall April 1
Spring November 1
Summer March 15
Please read the following to learn more about University of Utah Non-Matriculation policy.
Admissions Checklist for Non-Matriculated Students:
_______ Application for the Gerontology Certificate Program
_______ Transcripts
_______ Processing fee $15.00 (make check to Center on Aging)
(separate payment is required for the Admission application / please send two checks)
_______ Application for Permission To Register as A Non-Matriculated Student
(Non-Matriculated Students only)
_______ Non refundable-processing fee $35.00 ($60.00 late) (Non-Matriculated Students only)
(make check to University of Utah / separate payment is required for the Certificate program application)
Complete and send all application materials to:
University of Utah College of Nursing
Gerontology Program
Academic Advisor
10 South 2000 East
Salt Lake City UT 84112-5880
