The University of Texas School of Public Health

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You can use this form to reserve a place in a class. If you prefer to fax the information, please print this form and fax to 713-500-9750.

  1. Please tell us who you are and how we can reach you:
    Last Name
    First Name
    Title
    Organization
    Mailing Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country, if not U.S.A.
    Work Phone
    Home Phone
    Fax
    E-mail
     
  2. For what course would you like to register?
  3. What is your work setting?

  4. Please tell us your current major work projects so that we know your work interests and needs:

     

  5. Please use this space for any other information that might be of interest or help to the course instructors:


  6. Please indicate your method of payment:
    Check or money order Institutional purchase order
    in the amount of $ will be mailed within the next 10 days to:

    Continuing Education in Health Promotion
    University of Texas School of Public Health
    Attn: Mary Brown
    7000 Fannin, Suite 2574
    Houston, TX 77030

    Please note that institutional purchase orders will be invoiced upon receipt and should be paid before the first day of classes.

  7. Please confirm:
    I have read and understood the Additional Information and have printed out a copy for future reference.

  8. Would you like continuing education units for the course?
    for Certified Health Education Specialists (for all courses);
    My CHES number is
    for Registered Dietitians
    (for Helping People Change Nutrition and Dietary Behaviors)
    Other (please specify)


  9. If you would you like assistance in finding a roommate, please answer the two questions below:
    Are you male female
    Do you smoke? no yes

  10. We encourage participation by all people; if you need special assistance so that you may participate fully in the course, please let us know your disability and how we can meet your needs: