Completing this form lets us know you plan on working towards completing a certificate in Gerontology. It doesn’t bind you to doing so. However, if you complete this form and, later, program requirements change, you will be only be required to complete the program components required at time of competing this form. You can complete this 15 credit program in one year by taking one 7-week course at a time, or you can proceed at your own pace. Entering students should have completed at least 60 hours of undergraduate work or have significant work experience. Name * Date of Birth * mm/dd/yyyy Address City State Zip code Email * Approximate number of credits you have earned to date How did you hear about our programs?