General Information

Today’s Date:

Your Name (First, Middle Initial, Last)

Name as you want it to appear on the Certificate of Achievement:

Nickname:

Home Address:

City: State: Zip:

Home Phone:

Cell Phone:

Preferred E-mail Address:

Your Job Title:

Your Education Level:

Date of Birth:
(For security purposes, UGA is no longer collecting SS#; please complete birth date information for identification)

Organization Information

Name of Organization:

Address of Organization:

City: State Zip

Work Phone:

Fax:

Organization’s Website:

Supervisor’s Name (if sponsored):

Supervisor’s E-Mail Address (if sponsored):

Credit
I want Continuing Education Units (CEU’s)
I want Continuing Maintenance for CRC (CM-CRC)

Note: must be a Certified Rehabilitation Counselor to receive CM-CRC)
Certified Rehabilitation Counselor Number (CRC#):

My Experience Working With People With Disabilities Includes:

I Want To Participate In The Employment Specialist/Job Coach Program Because:

My Computer Skills Are:

Accomodations Needed:

Availability
Limited Space is available for this course. If the requested session is full, I would like to be placed on a waiting list for the next available course. Yes No

Tuition:
My personal check/money order for my full tuition is in the mail.
My organization’s check for my full tuition is in the mail.
My organization’s purchase order for my full tuition is in the mail. Please send an invoice.
I would like to develop a payment plan – please explain my options.

Make Check Payable To:

Human Services Management Institute

Philip E. Chase, Director
Human Services Management Institute
The University of Georgia
850 College Station Road
Athens, GA 30602

Please review the Cancellation Policy

Questions or Comments:

Thank You!