University of Rhode Island

For more information:

White Hall
University of Rhode Island
2 Heathman Road
Kingston, RI 02881-2021
Phone: 401-874-2766
Email: nurse@etal.uri.edu

College of Nursing

Thanatology Application Form

Questions marked with a * are required.

*First Name:

*Last Name:

*Email:

Address

*Telephone with area code:

Race:

	White
	Black
	Hispanic
	Native American
	Asian
	Other:

Gender:

*Date of Birth:

*When would you like to begin taking courses?

Marital Status:

Which time and place are you available to attend class?

	Afternoons (1-4pm)
	Late afternoons (4-6:45pm)
	Evenings (7-9:45pm)
	Weekends
	Providence Campus
	Kingston Campus

How did you learn of our certificate program?

Most recent college attended:

Years attended above college:

Major(s) at above college:

Other colleges attended, years attended and majors:

Current or most recent employment:

Title/Position:

Years at employer:

Please state your reasons for deciding to pursue a certificate in thanatology. Include your expertise related to dying and bereavement, any problems or issues that you would like to address in the field of thanatology and your professional goals.