Form

Department Chairs Certification Program Registration Form

Required icon – required field

Your registration form will not be stored or saved automatically during your registration process and cannot be saved over multiple sessions. Your data will only be saved after selecting the submit button at the bottom of this form. Registrants are encouraged to complete the form in one session. (All fields are required unless otherwise noted.)

Participation Requirements

Please note your attendance is required at all three session dates: Tuesday, July 11th, Wednesday, July 12th, and Thursday, July 13th. If you are unable to attend all three session dates, you will be unable to participate in the Summer 2017 Department Chairs Certification Program.

Personal Information

 
 
 
 
 
 
 
 
The following demographic information is optional.

Background Information

 
 
 
 

Self Evaluation

Please rate yourself, on a scale of 1 to 10, on each of the following items.
A rating of 1 is low - 5 can be considered average - 10 is high as possible.

 
 
 
 
 
 
 
 
 

Please respond to the following open- ended questions.

 
 
 

Participation Agreement

I understand that in order to complete the certification program, I am required to attend all sessions and take an online assessment.