Registration form for UW certificate program:
Geriatric Mental Health

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View program description

To register, please print, complete and mail this form with your payment to the address below.

(If paying with VISA or MasterCard, you may register by phone at 206-897-8939 or 1-800-506-1325, or by faxing this form to 206-685-9359.)

Registration is accepted on a first-come, first-served basis until the course limit is reached, or until 5 p.m. on the day before the first class meeting, whichever comes first.

Please complete the following for all courses:

Reg#	Course Title	Quarter	Course fee

Reg#	Course Title	Quarter	Course fee

Reg#	Course Title	Quarter	Course fee
Nonrefundable registration fee ($35 per quarter)
Total fees

Mr.    Ms.
Last name:
First name/middle initial:
Social Security # (required):
Date of birth:
Mailing address:
City/State/Zip:
Daytime phone:
E-mail address:

Method of payment:

	Check in U.S. funds made payable to the University of Washington. (Returned checks are subject to a $25 service fee.)
	Third-party payer: separate document (purchase order or letter of authorization to bill) must accompany this form.
	VISA
	MasterCard

Card number:
Expiration date:
Name as it appears on card:
Credit card billing address:
City/State/ZIP
Signature: