THE NATIONAL CATHOLIC BIOETHICS CENTER
NATIONAL CATHOLIC CERTIFICATION PROGRAM HEALTH CARE ETHICS
REGISTRATION FORM 2015/2016
REGISTRATION DEADLINE AUGUST 31, 2015
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 one of these is
required for the course. Please check one seminar location below.
Bismarck, ND
Philadelphia, PA
August 28 & 29, 2015
October 30 & 31, 2015
DOB – Month
DOB – Day
DOB – Year
US Citizen:
Yes
No
English Primary Language:
Yes
No
High School Graduate:
Yes
No
High School Name:
High School City:
HS Graduation Year:
College 1 Name:
1
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):
OPTIONAL QUESTIONS
How did you hear about the Program?
Religious Affiliation:
Marital Status:
Referred By:
Additional Feedback:
2
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 July 1, 2015)
*Certification Program Payment Policy
 $200 registration fee – non refundable
 Payment of balance of fees required before Sept. 14, 2015
 50% refund, less the cost of the materials, if the student withdraws before Sept. 14, 2015
 No refunds after the first module (Sept. 28, 2015)
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
Students registering for the Certification Program and wishing to receive graduate credit from the University of
Mary should contact Joan Mangino jrmangino@umary.edu for registration with UMary and the additional
$840 fee.
Tuition with University of Mary Graduate Credits $3740 Total:
$2900 (includes one year NCBC Individual Membership)
$840 additional (for 12 Graduate Credits payable to the University of Mary)
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, or 860-632-3070 for registration and payment
of fees.
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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
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Important Information About the NCBC Certification Program
Father Tadeusz Pacholczyk (Fr. Tad) will send you an email on September 7, 2015 with your first assignment
and with instructions for the program.
The two-day seminar is part of the Certification Program and attendance at one of these is a requirement of the
course.
August 28 & 29, 2015
October 30 & 31, 2015
Bismarck, ND
Philadelphia, PA
The year-long Certification Program in Health Care Ethics is e-mail based with assignments sent once a week
with one week to read and complete.
Calendar for 2015/2016:
Module I: Ethical & Religious Directives
4 weeks, September 7 - 28
Module II: Principles of Medical Ethics
4 weeks, October 5 – October 26
Module III: Catholic Bioethics and the Gift of Human Life
13 weeks, November 2, 2014 – February 8, 2016
(No module Nov. 23rd of Thanksgiving week or Dec. 21st of Christmas week)
Module IV: Case Studies
8 weeks, February 15 - April 11
(No module March 21st of Holy Week)
Case Study Seminar:
May 14, 2016 Philadelphia, PA
Final Paper:
July 1, 2016
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