Summer Institute PPLI Application Form

Please read and fill out the following application carefully. This does not automatically register you.  You will receive an email within 3 days from Gerry Barron to confirm or deny your application. All fields are required.

Name:    
Position:
Address:
Address:
City:
State:
Zip Code:
Agency/Organization:

Phone:
E-mail:
Are you in the Certificate Program in Public Health Preparedness and Disaster Response?
Please list the school(s) and department(s) you are enrolled in - and include the degree(s) you are pursuing (e.g., GSPH-Epid: MS, CAS-Psychology: BS).

I am only enrolled in the Certificate Program

Scholar Commitments

As an applicant to the Pennsylvania Preparedness Leadership Institute, I am prepared to commit to the following terms if accepted as a PPLI Scholar. Furthermore, I understand that if I do not fulfill these commitments, my continued participation will be subject to revview by PPLI organizers.

  • I will commit to my attendance at all PPLI Activities.
  • I will actively contribute to PPLI and fully participate in the team-oriented field project.
  • I will participate in all necessary phases of the evaluation of PPLI.
  • I agree to cooperate in the future marketing of PPLI as an alumnus/a by allowing for future publications to include comments and photographs, as related to PPLI and its activities.
  • I understand that email will be one of the primary methods of communication throughout the conduct of the Institute, therefore necessitating my maintenance of an active email account.
  • I understand that I am elegible to receive a full scholarship to the Institute upon review of my credentials, as proven with this application.

To be completed by the applicant:

PPLI will not share with, sell, or distribute any personal information such as phone number, postal address, zip code, name, or other provided information to third parties. Privacy is important and PPLI will not ask you to provide any non-public information.  

I have read the required conditions for Scholars of the Pennsylvania Preparedness Leadership Institute. I agree to the requirements stated as such.