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T e a c hin g M ediu m : E N GLIS H The CUHK Jockey Club School of Public Health and Primary Care Please visit for more details! Address: 2/F, School of Public Health Building Prince of Wales Hospital Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : [email protected] The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong Summer Course List Course Information as of April 30, 2014. JC School of Public Health and Primary Care (JCSPHPC) reserves the right to change / cancel any course due to unforeseen reasons; every effort will be made to avoid cancellations. In case of any changes and cancellations, announcement will be made over JCSPHPC website (www.sphpc.cuhk.edu.hk). Global Health PBHT5900 International Field Studies: Bangladesh June 19-24 POPG5006 Disaster & Humanitarian Crisis July 9-11 Health Improvement HSOC5102 Communicating Health Jun 21, 28, Jul 5,12 HSOC5210 Social Marketing Methods Jun 4,11,18,25,Jul 9,16 HSOC5211 Advanced Theories of Jul 8,10,15,17 Health Behaviours Health Protection INFD5007 Application of GIS in Public Health July 2, 4, 7, 10 INFD5801 Major and Neglected Tropical TBA Infectious Diseases of Poverty OENV5008 Water and Health June 25-July 2 OENV5801 Injury Prevention and Control TBA PBHT5005 Basic Human Physiology Aug 16,19,21,24,27,29 PBHT5801 Climate Change and Health July 14-15 Health Services HSYS5801 Health System & Public Health Early July Issues in China
Transcript
Page 1: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

Teaching Medium: ENGLISH

The CUHK Jockey Club

School of Public Health

and Primary Care

Please visit for more details!

Address: 2/F, School of Public Health Building Prince of Wales Hospital Shatin, New Territories, Hong Kong

Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489E-mail : [email protected]

The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong

Summer Course List

Course Information as of April 30, 2014. JC School of Public Health and Primary Care (JCSPHPC) reserves the right to change / cancel any course due to unforeseen reasons; every effort will be made to avoid cancellations. In case of any changes and cancellations, announcement will be made over JCSPHPC website (www.sphpc.cuhk.edu.hk).

Global Health

PBHT5900 International Field Studies: Bangladesh June 19-24POPG5006 Disaster & Humanitarian Crisis July 9-11

Health Improvement

HSOC5102 Communicating Health Jun 21, 28, Jul 5,12HSOC5210 Social Marketing Methods Jun 4,11,18,25,Jul 9,16HSOC5211 Advanced Theories of Jul 8,10,15,17 Health Behaviours

Health Protection

INFD5007 Application of GIS in Public Health July 2, 4, 7, 10INFD5801 Major and Neglected Tropical TBA Infectious Diseases of Poverty

OENV5008 Water and Health June 25-July 2OENV5801 Injury Prevention and Control TBAPBHT5005 Basic Human Physiology Aug 16,19,21,24,27,29PBHT5801 Climate Change and Health July 14-15

Health Services

HSYS5801 Health System & Public Health Early July Issues in China

Catherine
June 23-24
Christy
Christy
July 3-5
Page 2: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

Information as of May 26, 2014. 1

Introduction JC School of Public Health and Primary Care (JCSPHPC) of The Chinese University of Hong

Kong is an Asia-Pacific regional centre of public health research and teaching that strives to

maintain an internationally recognized standard of excellence in training public health

professionals and to advance the development of public health and primary care.

Global Health Summer School (GHSS) presented by JCSPHPC aims to construct a global

teaching platform for people from around the world to exchange ideas and update the

latest issues on relevant topics in public health, so as to further enhance and broaden their

knowledge base in public health-related areas, contributing to the success of protecting,

improving and providing health on a global perspective.

This year, GHSS offers a wide range of intensive summer courses across four domains,

namely Global Health, Health Improvement, Health Protection, and Health Services, which

are credit-bearing courses under the existing curriculum of Master of Public Health and

Master of Science in Health Education. Courses offered at GHSS are taught by academic

staff from The Chinese University of Hong Kong and international collaborative institutions;

non-public health based affiliates; and local and international experts. Individuals who are

interested in and want to further enrich and broaden knowledge in public health-related

disciplines, including existing JCSPHPC students; international students; public health

professionals; and members of the public, are welcome to apply.

Page 3: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

Information as of May 26, 2014. 2

Summer Course List

Global Health

PBHT5900 International Field Studies: Bangladesh Jun 19-24

POPG5006 Disaster & Humanitarian Crisis Jul 3-5

PBHT5804 Ethics, Social Justice and Global Health **NEW** TBA

Health Improvement

HSOC5102 Communicating Health Jun 21, 28, Jul 5,12

HSOC5210 Social Marketing Methods Jun 4,11,18,25,Jul 9,16

HSOC5211 Advanced Theories of Health Behaviours Jul 8,10,15,17

Health Protection

INFD5007 Application of GIS in Public Health Jul 2, 4,7,10

OENV5008 Water and Health Jun 25-Jul 2

PBHT5005 Basic Human Physiology Aug 16,19,21,24,27,29

PBHT5801 Climate Change and Health Jul 14-15

Health Services

HSYS5801 Health System & Public Health Issues in China Jun 26-27

Course Information as of May 26, 2014. JC School of Public Health and Primary Care

(JCSPHPC) reserves the right to change / cancel any course due to unforeseen reasons;

every effort will be made to avoid cancellations. In case of any changes and cancellations,

announcement will be made over JCSPHPC website (www.sphpc.cuhk.edu.hk).

Page 4: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

Information as of May 26, 2014. 3

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POPG 5006 Disaster and Humanitarian Crisis (1.5 credits / 18 hours) 3-5 July / Full Day Module Co-ordinator: Professor Emily Chan Disaster and Humanitarian Responses are crucial elements in public health practices in the global community. Humanitarian relief actions often highlight the importance of preparedness, training and multidisciplinary response actions. This course will offer participants an overview of public health and medical implication of disasters and humanitarian crisis. It discusses about health needs assessments and post-disaster evaluation. It aims to show how public health principles may be applied in disaster relief and health-related humanitarian actions. Topics: 1. Principle of Medical Humanitarian Responses in Disaster Crisis 2. Fundamentals of post disaster health needs assessment, disaster response and

planning 1) Disaster response cycle 2) Global disaster response policies (SPHERE) 3) Issues with medical and public health responses. (Health service provision, logistics

and prioritization) 3. Mental health and psychosocial support in emergency

1) Mental health implications of various types of disaster on different populations 2) Comparison of various initial public mental health interventions and clinical

response 3) Mental health needs assessment and coordination of services

4. Natural Disasters 1) Epidemiology of natural disaster 2) Health and medical implications of various types of disaster (Earthquake, floods and

meteorological related disasters) 3) Health needs of mobile population

5. Man-made Disasters 6. Complex Emergencies 7. Public health and medical response in disaster relief

1) Initial clinical needs and disease pattern including the direct and indirect mortality and morbidity

2) Public health and medical response to these events 3) Introduction to the role of medical specialties and health systems

8. Disaster preparedness, emergency response program, policy, planning and evaluation

Page 5: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

Information as of May 26, 2014. 4

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PBHT 5900 International Field Studies: Bangladesh (1 credit / 6 days ) 19 - 24 June / Full Day Module Co-ordinator: Professor Jean Kim This module is designed to allow students to conduct field studies abroad and to receive academic credit for their supervised work and studies. After completing the module, student should be able to: i) detail the health conditions or underlying health problems being addressed in their field studies, ii) have direct interaction with key players in the field studies setting, and iii) be able to contrast the public health situation of the field study site with that of  the  student’s  home  country.  Note:  This  course cannot be used toward Capstone-related practice hours. Global Health: Health Care System and Health Management in Bangladesh This course is offered by a private university in Dhaka, Bangladesh, in collaboration with faculty members from other institutions, including The University of Southern Mississippi, USA, The Chinese University of Hong Kong, State University of Bangladesh, NITOR, and Green Life Medical College, Dhaka, Bangladesh. This course based on a 7-day trip to Bangladesh, consists of lectures and field visits to selected sub-district health complexes, hospitals, laboratories and communities. Students will have the chance to meet senior health administrators, including former Director General of Health Services; Principal and faculty members of Medical Colleges and Directors of selected hospitals. Topics:

1. Health Care System in Bangladesh: Government and Private 2. Family Medicine in Bangladesh 3. Health Problems in Bangladesh

Page 6: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

Information as of May 26, 2014. 5

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PBHT 5804 Ethics, Social Justice and Global Health (1.5 credit / 3 days ) TBA / Full Day Module Co-ordinator: Professor Huso Yi This qualitative methods course will introduce students to basic ideas of public health ethics and justice and discusses how those ideas apply to global biomedical issues. Student should be able to:

1. Understand basic ideas about global health ethics and global justice. 2. Understand some key facts about current practices in health care and

medical research that have global consequences. 3. Judge the strengths and weaknesses of value arguments in the readings. 4. Express your own ideas and learn how to explain your reasons to other

people. Topics:

1. Public Health Ethics a. Public health ethics vs. bioethics b. Public health ethics framework

2. Global Health Ethics and Justice a. Global health ethics b. Ethics and alleviating world poverty c. Global justice, institutions and past wrongs

3. Ethical Issues in Global Health a. International clinical trials b. R&D for neglected diseases c. Pricing and access to essential medicines

Page 7: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

Information as of May 26, 2014. 6

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t HSOC5102 Communicating Health (2 credits / 24 hours) 21 Jun, 28 Jun, 5 Jul & 12 Jul (Saturday) / Full Day Module Co-ordinator: Professor Annisa Lee This course aims to equip students with theoretical foundation and practical skills to create health publicity campaigns. Topics

1. Who are the Audience? - Course Introduction - Communication Models - Case: Japan Tsunami Risk Communication - PRIZM Segmentation - Synovate Classmate Profiler - Department of Health Alcohol Campaign Briefing 2. What is the Message? - Positioning: Situation and Competitor Analyses - Creating Health Proposition and Message - Cases: Abdominal Obesity, Primary Care Doctors and Eatsmart at Preschool

Campaigns - Report Audience Survey - Creativity and Creative Brief - Brainstorming and Mind Mapping - The Hallmark Connection 3. Which Channels to Deliver? - Integrated Health Publicity Campaigns: Advertising, public relation, digital

platform, sales promotions, direct marketing and personal selling - Case: Eatsmart Restaurant Campaign - Alcohol Campaign: Individual Group Consultation 4. With What Effects? - Pretesting and Monitoring - Media Analysis - Campaign Evaluation and Appreciation - Case: Ad Council

Page 8: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

Information as of May 26, 2014. 7

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t HSOC 5211 Advanced Theories of Health Behaviours (1 credit / 12 hours) 8 Jul, 10 Jul, 15 Jul & 17 Jul (Tuesday or Thursday) / Evening Session Module Co-ordinator: Professor Phoenix Mo This course aims to provide students with a broad knowledge of psychological theories of health and illness and individual differences in health and illness. It aims to provide students with an appreciation of health behaviours, health beliefs, health-related cognitions, and individual differences in health & illness. Topics: 1. Past and current perspectives on health and illnesses 2. Models and theories of health behavior 3. Facilitating and inhibiting factors to health 4. Application of Theories in Health Promotion Practice and Research

HSOC5210 Social Marketing Methods (1.5 credits / 18 hours) 4 Jun, 11 Jun, 18 Jun, 25 Jun, 9 Jul & 16 Jul (Wednesday)/ Evening Session Module Co-ordinator: Prof. Joseph Lau The course aims at providing participants an overview of social marketing as an approach to health promotion. The course will cover key concepts and elements of social marketing, as well as the benchmark criteria for a social marketing initiative. The course will be conducted in a combined format of lecture and workshop. Examples of application of social marketing in health promotion will be illustrated in the course. Topics:

1. Introduction to social marketing 2. Analyzing the social marketing environment 3. Selecting targets, objectives and goals 4. Identifying benefits, barriers, and competitions; Positioning and branding 5. The 4Ps: Product and Price; Place and Promotion 6. Case studies: social marketing campaigns from around the world; and

Course conclusions

Page 9: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

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n INFD 5007 Application of GIS in Public Health (2 credits / 24 hours) 2,4,7,10 July / Full Day Module Co-ordinator: Dr. Erjia Ge Geographical Information System (GIS), integrating cartography, statistical analysis, and database technology, has been widely used in the study of public health, such as disease surveillance, risk assessment, and decision-making for public health practices. This course aims to offer a general introduction to GIS, including basic concepts, methodologies, and applications of health and environment issues. Topics: 1. Introduction to GIS 2. Understanding Health Data in Space 3. Geocoding for Health Data 4. Exploratory Spatial Data Analysis on Health 5. Starting a GIS Project on Health

OENV5008 Water and Health (2 credits / 24 hours) 25, 26, 27 Jun (Evening Session), 2 Jul (Morning Session), 28, 30 Jun (Full day) Module Co-ordinator: Professor Amal Mitra This a 2-credit course for graduate students. This course gives a brief introduction to water, environment, and health. Topics: 1. Water Cycle and Water Scarcity 2. Water in Life 3. Water Supply in the Third World Countries 4. Urban Slum: Effects on Water, Sanitation, and Hygiene 5. Water Regulations in Different Countries 6. Prevention of Diarrheal Diseases; Evidence of Some Successful Programs 7. Water Sampling and Analysis 8. Effect of Climate Change on Infectious Diseases 9. Industrial and Agricultural Exposure to Chemicals 10. Lead Poisoning 11. Arsenic Poisoning

Page 10: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

Information as of May 26, 2014. 9

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n PBHT 5005 Basic Human Physiology (2 credits / 24 hours) 16,24 August (Full Day) / 19, 21, 27, 29 (Evening) Module Co-ordinator: Professor Josette Chor This course is a basic introduction to the human body for public health students without a bio-medical background. It is geared towards students with an undergraduate degree in social sciences, arts and physical sciences. It will introduce the overview of basic scientific mechanisms, concepts and principles in health and in the pathogenesis of disease. It provides clinical scientific foundation for applications to the practice of public health. Professionals in the clinical health field such as physicians, nurses, dentists and allied health specialists will not be permitted to take this course for credit. Topics: 1. Introduction: Cells, Tissues, Organs and Systems, Genetics 2. Musculoskeletal System: Arthritis & Ageing and Falls 3. Respiratory System: Lung Cancer & Asthma 4. Gastrointestinal System: Gastroenteritis & Obesity 5. Neurological  System:  Alzheimer’s  Disease  &  Stroke 6. Circulatory System: Coronary Heart Disease (CHD) & Hypertension 7. Reproductive System: Infertility, Cervical Cancer & Impotence 8. Dermatology & Special Sense: Acne, Contact Dermatitis, Sensorineural Hearing Loss 9. Urinary System: Kidney Failure 10. Immune System and Hematological System: SLE & Leukemia 11. Diabetes and the Endocrine System: Hyperthyroidism and Hypothyroidism &

Metabolic Syndrome

Page 11: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

Information as of May 26, 2014. 10

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n PBHT 5801 Climate Change and Health (1 credit / 12 hours) 14-15 July / Full Day Module Co-ordinator: Professor Emily Chan Climate Change is an important topic for public health practices for the 21st century. This course offers participants an overview of issues related to climate change and health. It aims to show how public health principles may be applied in issues of climate change to support community preparedness, response, policy formulation and implementation. Topics: 1. Climate Change and Health Overview

1) What is climate change? An overview of recent scientific assessments 2) Quick revision of public health principles and their application for

understanding the health impact of climate change 3) Overview of the human vulnerabilities in climate change (extreme weather

events, temperature) 4) Global pattern and trends of adverse impact of climate change (high, low

income countries small island) 5) Current methodology for the assessment of health impact of climate

change 2. Methods to Study Disease Pattern of Climate Change

1) Projecting Future Health Consequences of Climate Change using Empirical Models fit to Existing Data

2) Use of Empirical and Process-Based Mathematical Models for Forecasting Changes in the Geographic Distribution of Infectious Diseases

3. Human Behaviour and Adaptation to Climate Change

Health Improvement: Human Behavior 1) Health Risk Perception 2) Behavior patterns (lifestyle, health risk management, health seeking

behavior) 4. From Science to Policy: Public Health Responses in Climate Change

Health Policy and Management 1) Public health burden of climate change 2) Global climate change and health policies and initiatives

Page 12: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

Information as of May 26, 2014. 11

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HSYS 5801 Health System and Public Health Issues in China (1 credit / 12 hours) 26-27 June / Full Day Module Co-ordinator: Professor Xiaolin Wei China has undergone profound reforms on its health system in recent years. In the

meantime, China faces multiple public challenges such as communicable disease

outbreaks, air and water pollution and a surge of chronic disease prevalence. This course

aims to  provide  basic  knowledge  of  China’s  health  system  on  its  organisation,  financing,  

payment, insurance, disease control, drug policies and priorities on recent reform.

Examples of key public health issues will be discussed. Group discussion and interactive

learning approach are to be used.

Topics:

1. Introduction to China Health System

2. China Public Health Issues, and Policy Brief Writing

3. Air Pollution and Health

Page 13: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

Information as of May 26, 2014. 12

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Venue and Time School of Public Health Building, Prince of Wales Hospital, Shatin, New Territories, Hong Kong. Full Day Session: 09:30 - 12:30 & 14:00 - 17:00; AM Session: 09:30 - 12:30; PM Session: 14:00 - 17:00; Evening Session: 18:30 – 21:30 Medium of Instruction All courses are taught in English. Tuition Fee Tuition Fee for 2014 summer courses is rated at HK$4,200 per credit. Each applicant is required to pay a non-refundable Application Fee of HK$100. Special Offer CUHK  and  JCSPHPC’s  current  students  and  graduates  can  enjoy  a  10%  discount. Admission Requirement Bachelor’s  honours  degree  (not  lower  than  second-class lower division honours, or B grade);  or  Bachelor’s  degree  in  medicine  or  an  approved  health  related  field. Certification Certificates will be awarded to students who have at least 75% attendance and obtain a “Satisfactory  Pass”  in  the  assessment  of  the  courses. CME Accreditation All the credit-bearing courses are CME accredited.

Page 14: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

!

Global Health Summer School 2014 APPLICATION FORM

Application Procedure Please complete the Application Form and submit it with academic supporting documents and crossed cheques payable to “The Chinese University of Hong Kong” by mailing to: Global Health Summer School 2014, 2/F., School of Public Health Building, Prince of Wales Hospital, Shatin, N.T., Hong Kong.

Application Deadline The deadline has been extended to 15 June, 2014. Application is on first-come-first-served basis. Enquiry Tel: (852) 2252 8429 / 2252 8488 Email: [email protected]

Please complete this form in BLOCK letters.

Title: Prof. / Dr. / Mr. / Ms. * Sex: M / F *

Name :

(In English)

(In Chinese) Surname Given name

HKID Card / Passport *No.:

Passport Issuing Country:

Correspondence Address:

Tel:

Mobile:

Fax:

Email Address:

Academic Qualifications

Institution & Location Diploma/Degree Date of Attendance (From / To)

Professional Qualifications

Professional Qualification Awarding Institution / Country Date of Award

Work Experience (In descending chronological order)

Institution & Location Position Date (From / To)

!

JC School of Public Health and Primary Care The Chinese University of Hong Kong!

!

Page 15: The CUHK Jockey Club School of Public Health and Primary …Shatin, New Territories, Hong Kong Tel : (852) 2252 8801 / 8488 Fax : (852) 2145 7489 E-mail : sphpc_courses@cuhk.edu.hk

!*Please delete as appropriate Ver.2014.05.16 Course Selection Application fee (non-refundable) HK$100 is required for each application.

Course Code Course Host

Prog^ Credit Unit

Tuition Fee

Please Check

the box Global Health

PBHT5000 Foundations of Public Health (Global) ***CANCELLED*** MPH 1 HK$4,200 PBHT5004 Tuberculosis: Biology, Behavior, Control and Policy *CANCELLED* MPH 1.5 HK$6,300

PBHT5804 Ethics, Social Justice and Global Health ***CANCELLED*** MPH 1.5 HK$6,300

PBHT5900 International Field Studies: Bangladesh MPH 1 HK$4,200

POPG5006 Disaster and Humanitarian Crisis MPH 1.5 HK$6,300

Health Improvement

HSOC5102 Communicating Health HED 2 HK$8,400

HSOC5211 Advanced Theories of Health Behaviours HED 1 HK$4,200

HSOC5210 Social Marketing Methods HED 1.5 HK$6,300

Health Protection

INFD5007 Application of GIS in Public Health MPH 2 HK$8,400

INFD5801 Major and Neglected Tropical Infectious Diseases of Poverty MPH 1.5 HK$6,300

OENV5008 Water and Health MPH 2 HK$8,400

PBHT5005 Basic Human Physiology MPH 2 HK$8,400

PBHT5801 Climate Change and Health MPH 1 HK$4,200

Health Services

HSYS5801 Health System and Public Health Issues in China MPH 1 HK$4,200

Application Fee (non-refundable) HK$100 ^MPH – Master of Public Health HED – MSc in Health Education Payment: (Please use separate cheques for Application Fee and Tuition Fee of each course).

Application Fee: HK$100 Cheque no.:

Bank:

Tuition Fee: HK$

Cheque no.:

Bank:

Tuition Fee: HK$

Cheque no.:

Bank:

Remarks: • No refund will be made after receipt of payment. • Acceptance of application is subject to availability. • A student visa is required if applicant do not have the right of abode/right to land in Hong Kong I declare that the information given in support of this application is accurate and complete, and understand that any misrepresentation will result in the disqualification of my application for admission. Signature:

Date:


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