Exit this survey Summer Institute 2016 Registration Form Question Title * Applicant Information First Name Last Name Job Title Organization Department Question Title * Contact Information Email Phone Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country (if outside the United States) CoursesChoose one area of study for the entire week, allowing for in-depth discussion and analysis. Please indicate which courses would be your first and second choices. If your first choice has low registration numbers, you may be asked to switch to your second choice. Question Title * Select your first and second choice course. These topics are contingent on sufficient enrollment. First Choice Second Choice Examining the Root Causes of Health Equity Examining the Root Causes of Health Equity First Choice Examining the Root Causes of Health Equity Second Choice Implementing Program Planning and Evaluation Implementing Program Planning and Evaluation First Choice Implementing Program Planning and Evaluation Second Choice Strategic Decision Making for Health Systems Leaders Strategic Decision Making for Health Systems Leaders First Choice Strategic Decision Making for Health Systems Leaders Second Choice EventsAlong with courses, participants attend a plenary session and special networking lunch with Leadership Institute and Management Certificate scholars. Help us provide an accurate count for catering by indicating whether or not you'll be able to attend. Question Title * I will be attending the opening plenary session (Monday, August 1, 8:30-10 AM). Yes No Unsure Question Title * I will be attending the networking lunch (Tuesday, August 2, noon-1 PM). Yes No Unsure Question Title * Section 2: SurveyThe Summer Institute for Public Health Practice would like to know how the program came to your attention. (Check all that apply) Postcard or flyer Past attendee Manager or supervisor Colleague Other word of mouth Webinar E-mail announcement Website NWCPHP staff or faculty Conference, meeting, or event Social media (Facebook, LinkedIn) Other (please specify) Question Title * Select the source which had the biggest influence on your decision to apply to the program. (Check one) Postcard or flyer Past attendee Manager or supervisor Colleague Other word of mouth Webinar E-mail announcement Website NWCPHP staff or faculty Conference, meeting, or event Social media (Facebook, LinkedIn) Other (please specify) Cost and DeadlineThe final application deadline for the 2016 Summer Institute is July 1, 2016. In order to receive the $900 discount rate, completed applications and full payment must be received by June 3, 2016. After that date, the regular program price is $1,200. PaymentAdvance payment is required and accepted in the order received. Accepted methods of payment include: credit card, purchase order, and check (made payable to the University of Washington). For credit card payments, please call Trudy San Jose White at 206.685.2931 or fax or mail in a completed payment form to Trudy at contact information below.Registration ConfirmationConfirmation will be emailed within one week of online registration. Contact Trudy San Jose White if you do not receive a confirmation.Cancellation and Substitution PolicyAll cancellations must be in writing. Refunds, less a $50 cancellation fee, will be issued up to July 18; after that date, registration fees are forfeited. Participant substitutions are permitted at no charge up to July 18. After that date, a $50 fee will be issued. No substitutions are allowed after July 22.Course Changes and Waiting ListCourse changes are allowed at no charge up to July 18, 2015. Course changes after this date will require a $50 course-change fee. If a course is canceled due to low numbers, participants will be notified and moved to their second choice at no extra cost. People on the waiting list will be notified if space becomes available and will have 14 days to pay their registration.PhotosThe Northwest Center for Public Health Practice (NWCPHP) may take photos and videos during the 2016 Summer Institute for use in its educational and promotional materials. By virtue of registering to attend the Summer Institute, you grant NWCPHP full rights without compensation to use any photos, videos, or recordings containing your likeness taken during the routine course of the event, by NWCPHP, the School of Public Health, and the University of Washington, without any further notice. This permission may be revoked in writing to NWCPHP. Where to Stay During the Summer InstituteNWCPHP makes arrangements with local hotels and on-campus housing, so Summer Institute participants get the best rates possible when staying in Seattle. As rooms fill up fast during the summer, we suggest making reservations as soon as possible. Please visit our lodging page for more information about rates and locations.Contact and Mailing InformationNorthwest Center for Public Health PracticeAttn: Trudy San Jose White / Summer Institute1107 NE 45th Street, Suite 400Seattle, WA 98105Phone: 206.685.2931Fax: 206.616.9415Email: sanjose@u.washington.edu Next
