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Dietetic Technology Program
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Academics Home
Registration
Print Version
Page Content
Student Interest Form
First Name
Last Name
Address
City
State
Zip
Email
Phone
Cell Phone
Please check all that apply:
1. I am interested in being contacted with information on classes and workshops related to this program
Yes
2. I have reviewed the
Dietetic Technology Consortium Program Curriculum
and I plan on completing the full certificate program.
Yes
3. I am considering completing the Dietetic Technology Consortium Program at CGCC
Yes
4. Approximately how many classes do you wish to take per term?
1
2
3
4 or more
5. I am interested in taking summer courses
Yes
6. I am willing to take a class at another MCCCD college if a class is not available at a time that meets my needs (classes are offered at PVCC, SCC, GCC, and MCC).
Yes
7. My schedule allows me to take: (please enter number of classes)
Day Classes
Evening Classes
Weekend Classes
On-line classes
8. I am interested in courses offered in:
Distance learning format (on-line or flex)
Traditional classroom format (face-to-face)
9. I would like to transfer into a 4-year degree program and pursue the Registered Dietitician (R.D.) credential
Yes
10. Please check other certifications that you would be interested in:
Dietary Managerial Certification
ACE Personal Trainer Certification (American Council on Exercise)
ACSM Health and Fitness Instructor Certification (American College of Sports Medicine)
ACE Group Fitness Instructor Certification
ACSM Personal Trainer Certification
Food Service (e.g. School Nutrition Association (SNA) Certification)
NASM Personal Trainer Certification (National Academy of Sports Medicine)
Other Allied Health degree / certifications: (please specify below)
NSCA Personal Trainer Certification (National Strength and Conditioning Association)
Other certification:
11. I would be interested in taking additional courses to help me specialize in:
Nutrition for Seniors (60+)
Obesity / Weight Management
Sports Nutrition
Lifestyle Coaching
Diabetes
Operating my own business
Other specialty:
12. What past professional or personal experience do you have in the field of health and fitness that has contributed to your interest in this program?
13. What is your Education Background?
High School Diploma
College AA/AAS Degree
College BS/BA Degree
College MS/MA Degree
Other Degrees or Certifications:
Chandler-Gilbert Community College
2626 East Pecos Road, Chandler, Arizona 85225-2499
Phone: 480.732.7000 · Fax: 480.732.7090
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