Educational Psychology Department Application Deadline: Dec. 15 th - Spring start April 15 th for Fall Start

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1 Educational Psychology Department Application Deadline: Dec. 15 th - Spring start April 15 th for Fall Start Please provide the following information. While you may enclose a Personal Vita with your application, it is important you respond to all of the items included on this application form. "See Vita" is not an acceptable response. Please type or print legibly: Date: 1. Name: (Last) (First) (Middle) 2. Present Address: (Street Address) (City) (State) (Zip) Permanent Address: (Street Address) 3. Phone (including area code): 3a. Address: (City) (State) (Zip) (Cell) (Home) (Work) 4. Social Security Number: 5. Program Applying To: Check only one box below (unless you wish to be considered for both a master's and doctoral specialty in Counseling/ Counseling Psychology, in which case check both Counseling Psychology and Professional Counseling and indicate your preference in your personal statement): Page 1 of 5

2 Counseling/ Counseling Psychology: Counseling Psychology, Ph.D. Professional Counseling, M.Ed. School Counseling, M.Ed. Salt Lake City, Utah Campus St. George, Utah Campus Professional Counseling * (Licensure Only) (Summer deadline: April 2, Fall deadline: July 2, Spring deadline: November 5) Learning Sciences: Learning and Cognition,* M.A., M.S., M.Phil. Rolling Deadline Learning and Cognition, Ph.D.* Rolling Deadline Instructional Design and Educational Technology, * M.Ed., M.A., M.S. Rolling Deadline Statistical and Research* Methods, M.Stat. (Fall deadline: March 1, Spring deadline: April 1) School Psychology: School Psychology, M.S., M.Ed. School Psychology, Ph.D. School Psychology (Licensure Only) Reading and Literacy: Interdisciplinary Literacy Studies,* Ph.D. (Deadline March 1) Reading and Literacy, M.Ed. * Elementary Education M.Ed. * (Fall deadline: April 1, Spring deadline: November 1) Page 2 of 5

3 Please complete this section ONLY if applying to the Reading and Literacy Program: Certification Record: Do you hold a teaching certificate? State: Type of Endorsement: Have you ever applied for admission for any University Utah certification programs? YES YES NO If Yes,, (Program) NO Year Granted: (Year applied) Page 3 of 5

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5 6. Academic Preparation. List below all colleges and universities currently or previously attended. Use additional paper if necessary. College/University Dates Attended Degree Date Awarded Major Minor 7. Academic Awards and Honors. List below any academic awards or honors you have received since graduation from high school (e.g., scholarships, scholastic honors, etc.). 8. Research Experience. List below any research experience you have gained as part of your current or previous academic training and/or professional work. Identify the nature of the research and your duties and responsibilities. 9. Publications/Papers/Presentations. List below any publications or conference papers you have authored or co-authored as well as any presentations (i.e., lectures, seminars, workshops) you have made to professional groups. List below any teaching experience you have gained as part of your current or previous academic training 10. Teaching Experience and/or professional work. Identify the nature of the teaching assignment and your duties and responsibilities. Page 5 of 5

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7 11. Employmen t History. List below your current and previous employment, beginning with your most recent job. You may also include appropriate volunteer work. Use additional paper if necessary. Employer Dates of Employment Job Title Duties and Responsibilities 12. Professional Licenses, Endorsements, or Certificates. List below any professional licenses, endorsements, or certificates that you hold. 13. References. List below the names of at least three (3) individuals who can provide an evaluative statement concerning your academic preparation and professional work appropriate for your intended field of study. At least two (2) of your references should be people who have direct knowledge of your previous academic performance. It is your responsibility to see that each of your recommenders receives one of the enclosed Recommendation Forms and ensure that these are completed and mailed back directly to the Department of Educational Psychology before the application deadline. The Recommendation Form can also be found as a PDF file on our website. Name Title Organization Rel a tionship (Teacher, Employer, etc.) 14. Financia l Support. The Department of Educational Psychology is not able to guarantee financial support for its entering students. Please indicate below how you plan to secure financial support for your graduate education if you are admitted. 15. Graduate Record Exam (GRE): The Department of Educational Psychology must receive your GRE scores (Verbal, Quantitative, Analytical Writing) before your application can be considered. If applying for the Ph.D. or M.Ed. in Reading and Literacy Program or the Elementary Education M.ED., only the Analytical Writing score is required. (Your scores must be received by the application deadline). Page 7 of 5

8 Please indicate the date you took (or will take) the GRE:(Date must be within the past five years) Page 8 of 5

9 16. Personal Statement. To assist the Department of Educational Psychology faculty in evaluating your application, please attach a brief two page (double-spaced) personal statement on separate sheets describing your career goals, the type of professional setting in which you would ultimately prefer to work, the types of professional and/or academic activities in which you hope to be engaged, and any other information you feel is pertinent to your current and future professional activities. Please consult individual program application procedures for additional guidance on the statement content. 17. Attestation Clause. Have you ever been dismissed or otherwise terminated from any post-secondary educational institution or academic program, or have you been convicted of a felony offense, or have you had a professional license, certificate, degree or similar credential revoked, suspended, or restricted in any way? YES NO If you answered YES, please enclose complete information along with this application regarding all details and circumstances of the incident(s). 18. I hereby certify that the information contained in this application and supporting documents is true and accurately discloses all matters requested. I understand that any omissions, misrepresentations, or inaccuracies in this application constitute cause for denial of my admission to and subsequent matriculation in the Department of Educational Psychology. (Signature) (Date) 19. Citizenship*: 20. Ethnic Origin**: *International Students should consult The Graduate School Bulletin regarding special application requirements. **This information is used for federal reporting purposes only, but is not required. Failure to provide this information will have no adverse effect on your potential for admission. For Questions or Comments: VOICE: (801) FAX: (801) (Kendra Wiebke, Program Specialist) URL: Please Return Application (no later than December 15th or other specified deadline) to: University of Utah Department of Educational Psychology 1705 East Campus Center Drive - RM 327 Salt Lake City, Utah

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