Consumer Health Advocacy Certificates Application

You may want to read this form first and consider your answers carefully so that you can fill it out in one session. You may also want to type your personal statement in another program, such as Microsoft Word, and then paste it into the appropriate box below when you are ready to complete your application.

You will be asked to attach a resume below and provide 2 references.

For more information about the application process and about our certificate programs, please visit www.patientpartnerships.org/education/apply/

*Contact us if you have previously applied to study in our Applied Advocacy Experience Clinical - we may be able to use the application items we have on file.

Personal Information
Name * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number * ### - ### - ####
Email *
Your Interest in the Certificate Program
Which certificate are you interested in pursuing? *
Professional Capstone Graduate

If you need help selecting the right certificate for you contact us at 608-265-6267 or learning@patientpartnerships.org
Format for learning? *
On-Campus Combination (On-campus & Online) Online
Have you taken an online course before? *
Yes No
Do you meet the technology requirements for this course? Click here to open in a new browser window. *
Yes No
Intent to Enroll

When would you like to enroll in the certificate program?
Term *
Year *
I plan to complete the Certificate in: *
1 Year 2 Years 3 Years

Certificate programs are best completed over one year (three semesters, which includes fall, spring, and summer). In certain circumstances, they can be completed in two semesters, but this requires a commitment of at least 20 hours per week.
Current Education, Employment, & Activities
Attach Your Resume *

Please attach a copy of your current resume in either PDF (Recommended) or Microsoft Word format.
Are you currently enrolled, or intending to enroll in any other educational programs? *
Yes No Other
What other activities (employment, volunteer work, hobbies, etc.) will you be engaged in while pursuing the Certificate? *
Approximately how many hours a week will you be able to devote to your Certificate studies? *
Educational Background

Beginning with the most recent, list all post-secondary institutions you have attended, including UW-Madison.
Name of School/College/University (1)
City, State
From (mo/yr)
To (mo/yr)
Degree Earned

(If applicable)
Name of School/College/University (2)
City, State
From (mo/yr)
To (mo/yr)
Degree Earned

(If applicable)
Other Schools/Colleges/Universities

As above, include the following information:
- City, State
- From (mo/yr) / To (mo/yr)
- Degree Earned (if applicable)
More About You

Please submit a personal statement of 300 words or less:
•Describe your health advocacy interest and any relevant previous experience.
•Articulate your career/personal goals related to patient advocacy and/or the health care system and your current understanding of the field of patient advocacy.
•Describe how you plan to use the skills obtained in the certificate program to improve healthcare access and/or navigation.
•Reflect on the question: “How can patient well-being best be prioritized in the emerging profession of patient advocacy?”
•Reflect on the question: “What is the role of social justice in health advocacy?”
•Share anything else you would like us to consider as we review your application.
Personal statement (max 300 words): *
Maximum Allowed: 300 words. Currently Used: 0 words.
References

Please provide 2 references below.
Reference #1 * First Last
Email (Ref #1)
Phone (Ref #1) * ### - ### - ####
Relationship to You (Ref #1) *
Reference #2 * First Last
Email (Ref #2)
Phone (Ref #2) * ### - ### - ####
Relationship to You (Ref #2) *
Other Application Requirements - Items to Submit

Please submit the following items to us after you have submitted this application:
1) Transcript(s) for any current program or course work and all prior degrees (copies or unofficial accepted),
2) One letter of recommendation,
3) Non-refundable application fee of $75 paid via-check or money order made payable to "The Center for Patient Partnerships"

You can mail the above items to:
Center for Patient Partnerships
Attn: Certificate Application
University of Wisconsin-Madison
975 Bascom Mall, Suite 4311
Madison, WI 53706-1399

*These instructions will also be emailed to you after you submit your application.
I understand that I must submit the 3 items above in order for my application to be complete and considered for review: *
Yes No
Certification

I certify that the information in this application is true and complete to the best of my knowledge and I understand that inaccurate information may affect my admission, enrollment or financial status.

I understand that some of the courses that make up the Consumer Health Advocacy Certificates require Consent of Instructor for enrollment and that acceptance into the Certificate program does not guarantee my enrollment in any course that meets Certificate requirements.

I further understand that acceptance into a Certificate program, and completion of individual courses does not guarantee completion of a Certificate.
I certify and understand the above: *
Yes No
Do Not Fill This Out

Wufoo

Personal Information

Your Interest in the Certificate Program

Intent to Enroll

Current Education, Employment, & Activities

Educational Background

Name of School/College/University (1)

Name of School/College/University (2)

Other Schools/Colleges/Universities

More About You

References

Other Application Requirements - Items to Submit

Certification