MPH Registration Request
This form is only applicable to MPH students who need to register for courses.
*Please consult your MPH Academic Advisor prior to completing this form.
Date form was submitted
*
/
Month
/
Day
Year
Date
Name
*
Last Name
First Name
UIW Identification Number
*
Phone Number
*
Please enter a valid phone number.
UIW Email Address
*
Confirmation Email
Select the applicable semester
*
Fall
Spring
Summer
Course(s) to be added:
*
By submitting this form, I confirm I have consulted my MPH Academic Advisor and authorize UIWSOM to register me in the course(s) requested above.
*
I agree
Submit
Should be Empty: