Information for Project FLOSP

Please complete all information as accurately as possible. To be added to our mailing list, submit completed information forms to Rebecca Helton by one of the following methods:

Print and mail to:

James Madison University
Communication Sciences & Disorders
MSC
Harrisonburg, VA 22807

Print and fax to (540) 568-8077

To submit form, choose SEND INFORMATION button at the bottom of this page

Social Security Number:

1. Name:

Phone:(H) (W)

2. Address:

3. Undergraduate Institution:

Overall GPA:

4. U.G. Major:

GPA: Baccalaureate Degree Obtained:

5. Are you currently employed by the public schools?		As an SLP?
School System:

6. Are you licensed by the State of Virginia?		Date license granted:
If yes, what kind of certification/licensure do you have?(Check below) You may fall into one of the following 3 categories:

	I. B.S. degree plus 15 hours of master's level coursework; full license or collegiate
	professional license with endorsement in SLP(Prior to 1993)

	II. B.S. with a provisional license
	(Effective August, 1995 through 1996 academic year)
	*If you fall into this category, note whether you have:

	A. completed 6 graduated hours (3 lang.; 3 artic/phon.)
	B. been accepted into graduated school
	C. passed Praxis Series tests

III. Do not fall into either of the above categories or unsure.

7. Are you trying to earn a Master's Degree in SLP?

8. If you have taken graduate courses, please complete the following:
Course Number&Title, When Taken, Where, Credits Earned, Grade

9. Have you taken the GRE's? Scores?: V Q A

10. Have you applied to JMU's graduate program? If yes, When?

11. Have you been accepted to JMU?:

Unconditionally Conditionally Unsure No

If accepted conditionally, have you met the conditions required?

If no, when do you anticipate meeting the conditions required?

If yes, have you sent a written request to have your status changed?

12. Have you completed 25 observation hours (required before a practicum may be taken)?

13. Do you have any supervised ASHA clock hours? If yes, how many?

When and where obtained?

14. When would you be most likely to take courses? Evening, Summer, Weekends

15. Indicate your greatest needs as a part-time graduate student (i.e., Classes, practicum)

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