Department of Public Health Sciences

Clinical Epidemiology and Study Design Registration

First NameMiddle InitialLast Name
 
Kerberos Login  (required for access to course materials)
  I do not have have Kerberos login, but will obtain one prior to the first day of the course.
 
Degree:
M.D.
D.O.
Ph.D.
Other
 
Mailing address:
Address:
City:State:Zip:
Phone:
E-mail:
(Used for course-related communication)
 
CC E-mail:
(Send registration confirmation to this address)
 
Please indicate your primary medical specialty or field of graduate study
 
Please select your CTSC affiliation if applicable:
   
 
Institutional Affiliation/Employer:
 
Department:
 
Position:
 
Tuition: $750 UCD/UCDMC, $850 All Others - PAYMENT DEADLINE: August 29, 2016
Check this box if you are employed by or affiliated with UCD or UCDMC
Cancellations after August 29, 2016 or "no shows" will not receive a refund.
Cancellations prior to August 29, 2016 will receive a refund with a service charge of $100.
 
Please select payment method. (Payment must be received before enrollment is confirmed.)
 
  Check payable to UC Regents:
Send check to:
Beverly Bock
UC Davis School of Medicine
Department of Public Health Sciences
One Shields Ave, Med Sci 1-C
Davis, CA 95616
 
  DaFIS Recharge Number:
Account:Sub-Account:
 
Payment Contact Person:
First Name:Last Name:Phone:
 
Please briefly describe your proposed research project or topic of interest:
You may either upload a document or enter description in the text box below.
(Minimum 2 sentences - Required for acceptance into course and appropriate group assignment.)
 
Upload proposed topic here:  
 
 
 
Continuing Medical Education Credits:
CME Credits Required    I do not require CME credits for this course
 
Last four digits of Social Security Number (for CME and transcript purposes only):
 
Special Dietary Needs:
Vegetarian   Vegan
 
Other Special Dietary need (specify)
 
 
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