PCC Professional Certificate Program Program Application

About You

First Name(Required)

Middle Name or Initial

Last Name(Required)

Credentials

Preferred name for personal communications with faculty(Required)

Email(Required)

About Your Current Employment or Organizational Affiliation

Your Current Employer or Affiliated Organization(Required)

Type of Organization(Required)

Select the option that best describes your organization.

Is this organization currently a Planetree member?(Required)

Yes

I'm not sure.

City(Required)

State/Region/Province(Required)

Country(Required)

Your Position(Required)

How long have you been in your current position?(Required)

Check if you are currently a full-time student.

To receive the student rate, please upload evidence to validate your status. Students are invited to upload a copy of their current student ID (with the date).

Max. file size: 16 MB.

Check if you are currently a volunteer patient/family partner.

To receive the patient/family partners rate, please upload evidence to validate your status. Patient/Family Partners can provide evidence in the form of an organizational ID, committee roster with dates or a signed letter validating your role on organizational letterhead.

Max. file size: 16 MB.

More About You

How did you learn about the PCC Emerging Leaders Program?(Required)

Personal Statement of Interest(Required)

What do you aim to achieve through participation in this program and why is person-centered care important to you? (500 words max.) Successful applicants will write at least 300 words.

Resume/Bio/CV(Required)

Max. file size: 16 MB.

Please upload a 1 page resume/curriculum vitae or biosketch.

Invoicing Preferences

Once accepted in the program, applicants will be invoiced for course payment and your place in the program will be secured once full payment is received. You have the option of being invoiced for the course fee only or for a discounted rate when you bundle together the course fee with the Fellows in Person-Centered Care application fee. For more on pricing, visit the FAQs at https://planetree.org/pcccertificateprogram/

Please indicate below your invoicing preference.(Required)

Invoice me for the course fee only.

Invoice me at the discounted rate for the course fee and Fellows application fee

PCC Professional Certificate Program Application

About You

About Your Current Employment or Organizational Affiliation

More About You

Invoicing Preferences