Healthcare Coding Certificate Declaration Form
This form let's us know what terms you will be enrolling in for the 2024-2025 academic year and will help us prepare an academic advising plan for you to apply for the Healthcare Coding Certificate Program fall term.
Email *
Select the term(s) you will be attending: *
Required
Name *
Address: *
City, State, Zip: *
Telephone Number: *
Chemeketa Email Address: *
If we have urgent matters, and are unable to reach you through your Chemeketa email address, do we have your permission to email your personal email? 

If yes, please provide personal email below:
 *
A copy of your responses will be emailed to .
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