DIETARY MANAGER PROGRAM APPLICATION FORM
PART I: STUDENT'S APPLICATION
Title (Mr./Mrs./Miss/Dr./etc):
Name:
Address (Street, Apt., Box):
City: State: Zip code:
Home Phone: Work Phone: E-mail:
Social Security No.:  
Date of Birth:  
CURRENT EMPLOYMENT
Facility Name: Current Position:
Facility Street Address:
City: St: Zip code:
Type of Facility (check one): Hospital Nursing Home Correctional Other:________________
Facility Fax Number:  
How did you learn about the Auburn University Dietary Manager Independent Study Program?:
EDUCATION (Circle below the highest level of education achieved)
High School College  
8 9 10 11 12 1 2 3 4 5  
Name of School:
Location: Area of Study:
Other Education: Length: Date Completed:

CONDITIONS OF ENROLLMENT

I understand and agree to the following conditions:

  • Enrollment entitles me to a maximum of 24 months to complete all course requirements including the final examination.
  • Enrollment may be terminated by Auburn University if I do not make satisfactory progress.
  • No refunds are granted after the enrollment process is completed.
  • This course does not carry any university credit, nor does admission to this course constitute admission to Auburn University.
  • I understand the Distance Learning Office retains the prerogative to select proctors and examination sites if it deems it appropriate or necessary for the maintenance or integrity of the program.
  • If I am a California resident, I have received approval from the California Department of Health Services to take this course for certification.

I acknowledge that in signing this application that enrollment in this course occurs upon acceptance of this application in Auburn, Alabama and that any issues concerning participation or termination of enrollment will be resolved in Auburn, Alabama.
Student Signature: Date:

Academic Integrity

Students are expected to complete their own work with honesty and integrity. Work not exhibiting honesty and integrity can be defined as copying another student work and/or submitting work for credit that is not your own work. A student registering in a Distance Learning course at Auburn University agrees to comply with the University's regulations and policies as noted in Section II, Title 12, of the SGA Code of Laws.

 
PART II: CLINICAL INSTRUCTOR'S APPLICATION AND ENDORSEMENT
To qualify as a clinical instructor, you must be a Registered Dietician with current American Dietetic Association status and have at least one year post-registration, full time experience in a practitioner role, and at least six months of this experience related to the subject matter of the program.
Name: Years of Experience:
Address (Street/Box):
City: State: Zip code:
Home Phone: Work Phone: E-mail:

Does your experience include at least 1 year post-registration, full-time experience in a practitioner role, and at least six months of the experience related to the subject matter of the program?
Yes No

If no, explain:

Check your current status and attach a photocopy of your registration card to this application.

Registered dietician -- ADA member
Registered dietician -- nonmember
Active dietician member -- not registered
Other: ___________________________

ADA Registration Number:

AGREEMENT

I recommend __________________________________________________(student) and agree to this applicant's enrollment in the Dietary Manager Independent Study Program. The student has good reading skills and is quite capable of following written instructions. I understand the student will have a maximum of 24 months to satisfactorily complete all course requirements including the final examination.

I agree to:

  • Guide and counsel the student as required
  • Be responsible for coordinating the entire 150 hours of field experience and directly supervise 50 of those hour in nutrition related learning experiences.
  • Evaluate the student's progress as required by the course.
  • Administer objective tests and send tests papers to be graded.
  • Maintain close communication with the program coordinator and staff.
  • Regularly advise the facility administrator of the student's progress.
  • Notify Auburn University if I will no longer serve as clinical instructor for this student.
Signature: Date:
 
PART III: ADMINISTRATOR'S ENDORSEMENT

I recommend __________________________________________________(student ) and agree to this applicant's enrollment in the Dietary Manager Independent Study Program. I agree that this facility will:

  • Provide a climate for learning and encourage the student.
  • Allow the student to complete a minimum of 150 hours of supervised on-the-job experiences that are required for the course.
  • Permit the student to use the facility to perform on-the-job learning activities.
  • Provide additional time for consulting\supervising dietitian to supervise the student's work related learning experiences. (At least 50 hours of contact between student and dietitian are required.)
  • Understand that enrollment entitles the student to a maximum of 24 months to satisfactorily complete all course requirements including the final examination. The minimum time required is six months.

I understand that no refunds will be granted after the enrollment process is completed.
Name Title:
Facility:
Signature: Date:
 
PART IV: PROGRAM DIRECTOR'S AGREEMENT

I agree to:

  • Provide oversight of the program content and procedures in order to maintain course quality and facilitate convenient and efficient course processes.
  • Provide consultation to the preceptor in the performance of the preceptor's student supervision duties.
  • Provide oversight of the course faculty/graders to assure appropriate assessment and consistency in the evaluation of student performance.
Signature: Date:
 
PART V: METHOD OF PAYMENT (Tuition must accompany this application. Make check payable to Auburn University)
TUITION FOR THIS PROGRAM IS $505.00 ($655.00 if you wish to purchase textbooks at time of enrollment. Prices are subject to change.)
Check __ VISA __ MasterCard __ Money Order __
Card No: Expiration Date:
Cardholder's Name:
Authorized Signature:
SUBMITTING APPLICATION
Mail Application to: Distance Learning Office
Petrie Annex
Auburn University, AL 36849-5611
The Program Director agrees to provide oversight of the program content and procedures in order to maintain course quality and facilitate convenient and efficient course processes, to provide consultation to the preceptor (clinical instructor) in the performance of the preceptor's student supervision duties, and to provide oversight of the course faculty/graders to assure appropriate assessment and consistency in the evaluation of student performance.
FOR MORE INFORMATION
Phone: (334) 844-3114 Fax: (334) 844-3125 E-Mail: audl@auburn.edu