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Pediatric Mental Health Certificate Application
Thank you and please reach out to Melissa if you have any questions or additional comments.
Melissa Betke - betkem@uwgb.edu
First Name
Last Name
Email Address
Occupation
Employer
Address (Street, City, Zip)
Involvement in working with pediatric mental health (Either at work or outside of work)
How long have you been interested in and/or working with pediatric mental health?
no experience
1-3 years
3-6 years
6-10 years
10+ years
Why are you interested in completing the UW-Green Bay Pediatric Mental Health Certificate program?
Please upload a written letter of support/recommendation from a colleague/supervisor that supports your enrollment and involvement in the Pediatric Mental Health Certificate Program through UW-Green Bay Continuing Education and Community Engagement.
Letter of support/recommendation, please include:
- Name
- Relationship to Participant
- Why you support interested participant to complete the certificate program
Drop files or click here to upload
Do you understand that in being selected as a participant of the program you are required to offer and provide a free 60-minute training to interested community members, parents, teachers and co-workers ( Training on what to include in the 60 minute training will be provided as well as assistance setting up and promoting your event) Events can take place at your workplace for your co-workers, local school for teachers, parents and friends or libraries for community members. Once you complete the certificate program, your name will be added to a registry of certified pediatric mental health participants. You may choose to remove your name from this list if you choose.
Yes - I understand and will complete the community training to complete the certificate.
No - I am not comfortable providing the 60-minute training and my applicatin will be withdrawn.
Would your workplace be interested in hosting the free community training that each participant will be required to do at the conclusion of the certificate program?
Yes - Please provide contact name and email for our team to reach out to you.
No, not at this time.
Anything else you would like us to know?
Thank you for your time and interest in the Pediatric Mental Health Certificate Program through UW-Green Bay Continuing Education and Community Engagement. We will review your application and respond to you within 7 days of submission.
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