APPLICANT CHECKLIST FOR THE HUMAN SERVICES PROGRAM This checklist is for your use. Do not include with your application.

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1 APPLICANT CHECKLIST FOR THE HUMAN SERVICES PROGRAM This checklist is for your use. Do not include with your application. The completed application, all required paperwork and information is due to the Human Services Program secretary before 5:00 pm on the last Thursday of April. Must meet WCJC college requirements for admission TSI complete Completed application for admission to the Human Services Program Copies of transcripts Once your completed application is received by the program secretary, you will be given the steps for completing a Criminal Background Check and a Program and Practicum Policies Agreement Form. Once you have completed the Criminal Background Check and turned in the signed Program and Practicum Policies Agreement Form, you will need to contact via the Program Director, Ms. Schultz at to set up an appointment to review the certificate or degree plan check list that you have selected to pursue. I understand upon acceptance into the Human Services Program it is a requirement of the program and my responsibility to designate my major as Human Services with WCJC. Please submit the completed application and all required paperwork to: Wharton County Junior College Attn: Kelly Crosson 911 Boling Highway Wharton, TX If you have any questions regarding the application process, please call: Kelly Crosson at (979)52-69.

2 HUMAN SERVICES PROGRAM Name: Last First Middle Maiden Address: No. and Street or P.O. Box City County State Zip Social Security # Date of Birth WCJC Student ID# WCJC Student address Other Address Telephone Home Telephone Cell Telephone Work Have you ever enrolled in courses at WCJC? Yes No When? Are you applying for the certificate or associate degree? Certificate AAS Degree Are you currently attending college courses anywhere? Yes No If yes, where and what type of courses? You must be TSI satisfied college level in your reading, writing, and math to complete the academic courses required for the AAS in Human Services. Are you TSI satisfied? Yes No I have taken and passed the: National ACT National SAT COMPASS Accuplacer Quick THEA or other entrance exams accepted at WCJC and scores are on file with WCJC. Copy of test scores must be submitted to the Human Services Program. Date test taken: Location: I am currently enrolled as a Human Services major with WCJC? Yes No If no, upon acceptance to WCJC, designation of Human Services as my major is a requirement. Previous colleges, universities attended: College/University City and State Dates Attended Major/Degree Earned

3 Other Educational Programs Attended/Completed (include Vocational) Name of Program/School City and State Dates Attended Course of Study Work experience related to the Human Services Occupation Location Dates of employment Names, addresses, and occupations of three references (not relatives) Name Address Occupation Have you ever been convicted of a misdemeanor or felony? Yes No This includes: pleas of guilty, pleas of nolo contendere, withheld or deferred adjudication, suspended or stay of sentence, and military court-martial. If you check yes, please contact the program director or program secretary for further instructions regarding the application process. I certify that this application, test scores and all other required and submitted documentation as complete and accurate. I understand that these documents are being used to make an academic decision regarding admission to the Human Services Program. I understand that inaccurate or omission of information will make me ineligible for admission to or progression through the program. Signature: Printed name: Date: FOR HUMAN SERVICES PROGRAM (Do not write in this space) Application received Application complete Background check Certificate AAS Practicum Approval App. Updated Wharton County Junior College does not discriminate on the basis of race, color, age, marital status, national origin, religion, sex or disability.

4 WCJC HUMAN SERVICES PROGRAM CERTIFICATE CERTIFICATE CHECKLIST Printed Name WCJC ID# Phone number address Course number Course name Credit hrs. SCWK 121 Orientation to Social Services COSC 101 Introduction to Computing Grade Received Where When DAAC 119 Substance-Related and Addictive Disorders CHLT 109 Community Ethics CHLT 102 Wellness & Health Promotion CMSW 109 Problems with Children and Adolescents PSYT 129 Interviewing and Communication Skills DAAC 117 Basic Counseling Skills CHLT 140 Community Health Advocacy GERS 142 Aging and Mental Health PSYT 25 Family Systems PSYT 221 Crisis Intervention PMHS 2260 Clinical Psychiatric/Mental 2 ** (CC) Health Service Technician ** Contact Program Director (CC) Capstone Course Updated: Effective Date: Fall, 2015

5 WCJC HUMAN SERVICES PROGRAM AAS DEGREE DEGREE CHECKLIST Printed Name WCJC ID# Phone number address Course number Course name Credit hrs. SCWK 121 Orientation to Social Services ENGL 101 Composition I MATH 142 Introduction to Statistics DAAC 119 Substance-Related and Addictive Disorders CHLT 109 Community Ethics CHLT 102 Wellness & Health Promotion DAAC 117 Basic Counseling Skills COSC 101 Introduction to Computing PSYT 129 Interviewing and Communication Skills CHLT 140 Community Health Advocacy GERS 142 Aging and Mental Health PSYT 25 Family Systems PSYC 201 Introduction to General Psychology PSYT 245 Principles of Behavior Management & Modification CMSW 109 Problems of Children and Adolescents GOVT 205* Federal Government or or SOCI 106 Social Problems Humanities or ***Elective from AAS Visual/Performing General Education Course List Arts elective*** SCIENCE *Elective from General 4 elective * Education Core List for AAS Degree PSYT 221 Crisis Intervention PSYT 2164 **(CC) Practicum Clinical Psychology- 1 CHLT 2166 **(CC) Field Experience Practicum- Community Health Services/Liaison/Counseling-Field Experience Grade Received Where *Students intending to transfer to a 4-year university should take Science and Government courses **Contact Program Director (CC) Capstone Course ***This elective must be selected from the list of core requirements for AAS degrees. Updated: Effective Date: Fall, When

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