THE NATIONAL CATHOLIC BIOETHICS CENTER
NATIONAL CATHOLIC CERTIFICATION PROGRAM HEALTH CARE ETHICS
REGISTRATION FORM Mid-Academic Year, 2016
REGISTRATION DEADLINE FEBRUARY 10, 2016
First Name:
Middle Name:
Last Name:
Gender:
Billing Address:
City:
State:
Zip Code:
Country:
Primary Phone:
Work Phone:
Primary E-mail:
Second E-mail :
The two-day seminar is a supplemental part of the Certification Program and attendance at this seminar is
required for the course. Please check seminar below.
Dallas, TX
April 8 & 9, 2016
University of Dallas, School of Ministry
Bismarck, ND
August 12 & 13, 2016
University of Mary, School of Business
Philadelphia, PA
September 9 & 10, 2016
Archdiocesan Pastoral Center
DOB – Month
DOB – Day
DOB – Year
US Citizen:
Yes
No
English Primary Language:
Yes
No
High School Graduate:
Yes
No
High School Name:
1
High School City:
HS Graduation Year:
College 1 Name:
Graduation Year:
College 2 Name:
Graduation Year:
College 3 Name:
Graduation Year:
Current Employer:
Occupation:
Position:
Brief Description of your work:
Short Essay (why you are interested in the certification program):
2
OPTIONAL QUESTIONS
How did you hear about the Program?
Religious Affiliation:
Marital Status:
Referred By:
Additional Feedback:
Option 1: Payment for the Certification Program Only
$200 Non-Refundable Deposit Required
This registration fee will be applied towards your tuition.
Tuition:
$2900 (includes one year NCBC Individual Membership)
or
$2650 for Current NCBC members (as of January 15, 2016)
*Certification Program Payment Policy
 $200 registration fee – non refundable
 Payment of balance of fees required before Feb. 17, 2016
 50% refund, less the cost of the materials, if the student withdraws before Feb. 30, 2016
 No refunds after the first module (March 16, 2016)
Option 2: Payment for Certification Program Students Receiving Graduate Credit from the University
of Mary
$200 Non-Refundable Deposit Required
This registration fee will be applied towards your tuition.
12 Graduate Credits are available from the University of Mary in Bismarck, ND for an additional $840
I would like to receive graduate credits from the University of Mary:
Yes
No
Tuition, with University of Mary Graduate Credits:
$2900 (includes one year NCBC Individual Membership) + $840 for 12 Graduate Credits = $3740
*Certification Program Payment Policy
 $200 registration fee – non refundable
 Payment of balance of fees required before Feb. 17, 2016
 50% refund, less the cost of the materials, if the student withdraws before Feb. 30, 2016
 No refunds after the first module (March 16, 2016)
3
Option 3: Payment for Certification Program Students Receiving Graduate Credit from Holy Apostles
College and Seminary
9 Graduate Credits are available from the Holy Apostles College and Seminary in Cromwell, CT for the fee of
$3780 (includes certification + graduate credits).
Students wishing to register for the Certification Program and receive graduate credit from Holy Apostles
should contact Jennifer Arel directly at jarel@holyapostles.edu 860-632-3070, for registration and payment of
fees.
Payment Form:
* I have read the Certification Program Payment Policy above for Option 1/Option 2, and agree to its terms:
_____Yes
_No
**NCBC Enrollment policy for obtaining graduate credits:

Graduate Credits from University of Mary: If students enroll through Option 1 rather than Option 2,
it will still be possible to request and make payment for graduate credits from the University of Mary at
any time up to five years following successful completion of the NCBC Certification Program.

Graduate Credits from Holy Apostles College and Seminary: It is possible to request graduate
credits from Holy Apostles only by indicating interest and making payment at the time of enrollment.
Obtaining graduate credits at a later date is not possible. If I am enrolling only for the NCBC
Certification Program (Option 1), I hereby waive my opportunity to subsequently receive academic
credit through Holy Apostles College and Seminary. Agree to Terms:
Yes
No
Name on Card:
_____________
Card Type:
Card Number:
Expiration:
Security Code:
Check enclosed:
Yes
No
Return Form to:
Mail: Julie Kelley
The National Catholic Bioethics Center
6399 Drexel Road
Philadelphia, PA 19151
Fax:
215-877-2682
E-mail: jkelley@ncbcenter.org
4
Important Information About the NCBC Certification Program
Father Tadeusz Pacholczyk (Fr. Tad) will send you an email on February 17, 2016 with your first assignment
and with instructions for the program.
If you have not participated in an NCBC seminar within the past two years attendance at one of the two-day
seminars below is mandatory for Certification Program.
Dallas, TX – April 8 & 9, 2016
Bismarck, ND – August 12 & 13, 2016
Philadelphia, PA – September 9 & 10, 2016
The year-long Certification Program in Health Care Ethics is e-mail based with assignments sent weekly with
one week to complete and submit.
Mid-Academic Year Certification Program Calendar for 2016:
Module I: Ethical & Religious Directives
4 Weeks, February 17 - March 9
Module II: Principles of Medical Ethics
4 weeks, March 16 - April 13
(No module Holy Week)
Module III: Catholic Bioethics and the Dignity of the Human Person
13 weeks, April 20 - July 13
Module IV: Case Studies
8 weeks, July 20 - September 7
Case Study Day Seminar, Philadelphia (Required)
November 5, 2016
Final Paper Due
December 13, 2016
5