MADISON COLLEGE
Dietary Manager (DM) and/or Eating Behaviors Technician (EBT)
Certificate Programs
NEW STUDENT APPLICATION PACKET
Program Eligibility Requirements
To apply for admission into the Dietary Manager Program, students must meet the following eligibility
requirements:




Students must have a High School Diploma or Equivalent.
Students must have two years of food service employment OR post-high school training in the foods area plus 1
year of food service employment.
Students must be presently employed in a food service institution.
Students must be able to arrange their own preceptor. Your preceptor must be a Registered Dietitian with 2
years of post-registration experience. For the Dietary Manager Certificate, your preceptor will be responsible
for ensuring that you receive 150 hours of quality field experience, of which, 50 must be directly supervised and
recorded by your preceptor. For the Eating Behavior Technician Certificate, your preceptor will oversee your 60
hours of field experience during the General Nutrition and Medical Nutrition Therapy 1 courses. The Food
Service Institution by which you are employed must be willing to cooperate and fill out the required forms (see
below).
Application Requirements
If you meet the above eligibility requirements, please complete the following forms for the appropriate individuals:
1. Student Application for Admission (Completed by the prospective student)
2. Recommendations of Employer for Enrollment (Completed by prospective student’s current job Supervisor)
3. Agreement of Food Service Institution (Completed by the Administrator/Manager of Institution)
4. Preceptor’s Agreement (Completed by the Registered Dietitian chosen by the prospective student)
Upon completion of these forms, please return them to:
MADISON COLLEGE
Attn: Michael Braun
3550 Anderson Street
Madison, WI 53704
Phone: (608) 246-6313
MADISON COLLEGE
Dietary Manager’s Program
PRECEPTOR'S AGREEMENT
NAME:
HOME ADDRESS:
HOME TELEPHONE:
PRESENT POSITION IN DIETETICS:
Position:
Start Date:
Phone:
Ext:
Institution Name
Address
To which address would you prefer we send information pertaining to the programs?
Home ____Work
FORMER POSITIONS IN DIETETICS:
Position 1:
Start-End Dates: _______________
Institution Name
Address
Position 2:
Institution Name
Address
Start-End Dates: _______________
IT IS MY UNDERSTANDING THAT I WILL:
1.
2.
Attend preceptor meetings.
For the student working toward the Dietary Manager Certificate: Provide my student(s) with a total of One
Hundred Fifty (150) hours of on-the-job field experience, including Thirty-Fifty (30-50) hours of those
hours in nutrition related experience. For the student working toward an Eating Behavior Certificate:
Provide my student(s) with a total of Sixty (60) hours of on-the-job field experience.
SIGNATURE
DATE
*Please attach a copy of your registration card to this form.
MADISON COLLEGE
Dietary Manager Program
STUDENT APPLICATION FOR ADMISSION
PROGRAM :
________Dietary Manager _____ Eating Behavior Technician
DATE:
YEAR/SEMESTER:
NAME:
(Last)
SOCIAL SEC#:
(First)
(MI)
________ Male
Female
HOME ADDRESS:
(Include Zip Code Please)
TELEPHONE:
EMAIL: _____________________________________BIRTH DATE: _____________
EDUCATION:
Last Grade Completed
Name of Institution:_
List names of high schools and institutions of higher learning that you have attended:
Name and City, State of School
Dates
Degree Conferred
_______________________________________
__________
______________
_______________________________________
__________
______________
_______________________________________
__________
______________
_______________________________________
__________
______________
Why are you interested in enrolling in this course?
CURRENT EMPLOYER
Institution Name
Address
Number of Years Employed:
Job Title:
Responsibilities:
PREVIOUS POSITIONS IN FOOD SERVICE:
1.Institution Name
Address
Number of Years Employed:
Job Title:
Responsibilities:
2.Institution Name
Address
Number of Years Employed:
Job Title:
Responsibilities:
OTHER WORK, WHICH MAY BE OF INTEREST:
1.
Number of Years Employed: Job Title:
2.
Number of Years Employed: Job Title:
MADISON COLLEGE
Dietary Manager Program
FOOD SERVICE FACILITY AGREEMENT
It is our understanding that
will
(Name of Institution)
cooperate in the following area to ensure a quality learning environment for
employee __________________________________, if accepted as a student
(Name of Student)
in the Madison College Dietary Manager Program:
1.
Provide opportunities for our student(s) to achieve maximum knowledge, skills and abilities
essential for personal growth and job success as Dietary Managers.
2.
This facility will share responsibilities with the school by providing a preceptor who is a
registered dietitian with no less than one year post-registration job, full-time experience in a
practitioner role, and at least six months of this experience is related to the subject matter of the
program. The preceptor is responsible for coordinating the entire 150 hours of field experience,
and directly supervising or coordinating 30-50 hours in nutrition related experience.
3.
Your support represents a sincere interest in not only the student’s success but also the quality
of your food service staff as a whole. We encourage you to reach a mutually acceptable
agreement with the student (For example, you want to agree to pay for books upon
successful completion of the course, which could be used by another food service employee
in the future).
______________________________________________________________________________
*Signature – Administrator or Manager of the Facility
__________________
Date
RECOMMENDATIONS OF EMPLOYER
FOR ENROLLMENT IN DIETARY MANAGER PROGRAM
Determine the number of candidates you wish to enroll in our Dietary Manager Program
by considering the variety of potential positions you have available at your facility.
TO BE COMPLETED BY EMPLOYER, ADMINISTRATOR AND/OR DIETITIAN.
Applicant's Name: _______________________________________________________
Number Of Years In Your Employ: ___________________
Work Ethics/Characteristics:
Responsibilities:
Ability to work with people:
YES
or
NO ______
Ability to direct work of others: YES
or
NO ______
General attitude toward teamwork:
Sick leave and absence record:
Personal appearance:
Personality:
Do you believe this candidate has the aptitude and the intelligence for further
promotion and taking on additional responsibilities?
YES
_ or NO ______
Institutional/Work Environment:
Type of institution - General
Special_____
Total beds: ______
Number of employees in Food Service Personnel - Full time
Part time ____
Facilities in Dietary Department: Excellent _ Good
Fair___
Why does your institution encourage the applicant take this course?
What do you plan for recognition of the student during or upon completion of training ?
Check:
Monetary _ Changing position _ Job reclassification___ Other_______________
Registered Dietitian who will act as preceptor:
Name
R.D. No. ___________________
Title________________________________________________________________
Telephone (Work)
(Home)___________________________
Additional Comments:
Upon completion of these forms, please return them to:
MADISON COLLEGE
Attn: Michael Braun
3550 Anderson Street
Madison, WI 53704
Phone: (608) 246-6313
Email: [email protected]
Approval by Madison College: __________________________________, Michael Braun, MS, RD,
CD, Program Director and Instructor, Madison College Dietary Managers Program
Date __________________________
Student Name_______________________________