Social Security Number:

Name:

Phone:(H)

Phone:(W)

Address:

Undergraduate Institution:

Overall GPA:

U.G. Major:

GPA:

Baccalaureate Degree Obtained:

Are you currently employed by the public schools? YES NO

As an SLP? YES NO

School System

Are you licensed by the State of Virginia? YES NO

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.) YES NO

B. been accepted into graduated school YES NO

C. passed Praxis Series tests YES NO

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

Are you trying to earn a Master's Degree in SLP? YES NO

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

Have you taken the GRE's? YES NO

Scores?:

V

Q

A

Have you applied to JMU's graduate program? YES NO

If yes, When?

Have you been accepted to JMU?:

Unconditionally

Conditionally

Unsure

No

If accepted conditionally, have you met the conditions required? YES NO

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

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

Have you completed 25 observation hours (required before a practicum may be taken)? YES NO

Do you have any supervised ASHA clock hours? YES NO

If yes, how many?

When and where obtained?

When would you be most likely to take courses?

Evening

Summer

Weekends

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