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Application for the Dissemination & Implementation Graduate Certificate Program

Please fill out all the required fields and complete the program questions below. This form is only for AMC Graduate students who plan to enroll in the Summer or Fall of 2022.

Name*
Mailing Address*
Please include the best number where you can be reached by phone.
Please include an alternate number where you can be reached.
Gender*
Use format mm/dd
What semester are you applying?*

Diversity Information

The University of Colorado Denver | Anschutz Medical Campus (CU Denver/Anschutz) works to diversify the biomedical science field by training exceptional scientists from all backgrounds. In conjunction with its overarching mission to promote broad diversity in its student population and its NIH-funded research endeavors, CU Denver/Anschutz seeks to recruit and retain individuals from underrepresented racial and ethnic groups, individuals with disabilities, and individuals from socially, culturally, economically, or educationally disadvantaged backgrounds. Data collected here are always presented in a de-identified form, predominantly only in aggregate, and customarily only to organizations with a need-to-know status like the National Institutes of Health and the National Science Foundation (typically in conjunction with applications for funding).

The next several questions will help us ensure we are including a diverse group of applicants. 

Race/Ethnicity

Disclosure of race and ethnicity is voluntary. CU Denver is an equal access and equal opportunity university.

Are you Hispanic or Latino?*
Check which one of the following groups you consider yourself a member.*
I have a physical or mental impairment that substantially limits one or more major life activities.*
I come from a family with an annual income below established low income thresholds.*
I am the first generation to go to college.*
I come from a challenging social, cultural or educational environment.*

Affiliation and Academic Appointment (if applicable)

Affiliation: select your primary affiliation*
Enter N/A if not applicable.
Enter N/A if not applicable.

Graduate Degree Information

Are you currently applying for or enrolled in another graduate degree program at the University of Colorado?*
Please note: If you are accepted to the D&I Graduate Certificate Program and are enrolled concurrently in another degree program at the University of Colorado, it will be important to communicate with the Certificate program director and administrative staff about the timing of courses and graduation. More information will be provided to students who are accepted to the Certificate program.
Are you applying to the D&I Graduate Certificate Program as part of the ACCORDS HRSA Primary Care Research Fellowship?*

Program Questions

Please write a brief statement for each of the questions below. Please limit response to 200 words per question. 

Please limit your response to 200 words.
Please limit your response to 200 words.
Please limit your response to 200 words
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Please include transcripts from your highest degree (must include transcript legends). These can be official or unofficial. MD applicants must include an undergraduate transcript in addition.
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How did you hear about the University of Colorado Graduate Certificate in D&I Science?
Select all that apply
By submitting your application you certify that to the best of your knowledge, the information submitted on this application is true and complete. You understand that if found to be otherwise, it is sufficient cause for refusal or dismissal. If information provided in this application changes after submission, you must notify the Office of Graduate Admissions. You also understand that if admitted, your admission is contingent upon your final credentials reflecting academic achievement similar to the assessment at the time of your admission. If you enroll as a student at the University of Colorado DenverAnschutz Medical Campus, you acknowledge that you are responsible for adhering to all university regulations and for all financial obligations incurred. You understand that if you are classified as a non-resident for tuition purposes, and you have not petitioned for a change in your status by the first day of classes, you will remain classified as a non-resident for the entire semester and must submit a petition to request a change in your status for a future term. Proof of age and proof of local employment or additional information may be required by the Tuition Classification Officer. You also consent to the release of any materials relevant to an admission decision to the University of Colorado Anschutz Medical CampusDenver. In order to submit your application you must make arrangements for payment of the application fee. Your application will not be reviewed until the application fee payment is received in the admissions office. The application fee is NON-REFUNDABLE. In place of your signature, please type your full legal name:
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