Certificate programs application



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UNIVERSITY OF CONNECTICUT

College of Agriculture, Health and Natural Resources

DEPARTMENT OF ALLIED HEALTH SCIENCES

CERTIFICATE PROGRAMS APPLICATION



General Admission Statement
The Department of Allied Health Sciences offers certificate programs in Diagnostic Genetic Sciences (DGS) in Cytogenetics or Molecular Diagnostics, and Medical Laboratory Sciences. Students are eligible for admission to these professional programs after (a) completion of a Bachelors Degree; and (b) completion of all prerequisite coursework for the program of choice.
NOTE: Applicants who have not fulfilled all required prerequisite coursework must complete any unmet requirements prior to enrolling in the practicum semester. It may be possible to take all or some of the unmet course requirements during the semesters on the Storrs campus, at the discretion of the Program Director, and depending upon the availability of specific courses in the semester in question.
Program of Application: (IMPORTANT: please read all instructions prior to completing this section)
Applicants may apply to more than one program provided they meet the admission requirements for each. Please prioritize your choice(s) (e.g. 1st, 2nd, 3rd, etc.) next to the appropriate certificate program.

  1. I am applying for admission to the certificate program(s) indicated below:

_____ DGS - Cytogenetics

_____ DGS – Cytogenetics – Clinical Semester Only (Only available to UConn DGS graduates)

_____ DGS - Molecular Diagnostic

_____ DGS - Molecular Diagnostic – Clinical Semester Only (Only available to UConn DGS graduates)

_____ Medical Laboratory Sciences (MLS).


2) For the semester beginning:

  • Fall semester 20____

  • Spring semester 20____ Note: MLS Program only has a Spring semester start date

My signature certifies that the personal and academic information given on this application and in the supporting documentation is complete and accurate. Failure to disclose fully and accurately all facts relating to this application may be grounds for revocation of admission.


________________________________________ _____________________________________ ___________

Student Name (Please PRINT) Student Signature Date


The Certificate Programs application may be filed anytime within the year prior to projected matriculation. International students MUST apply at least six months prior to matriculation. Applications are reviewed three times a year: March, July, and October.

The University of Connecticut supports all federal and state laws that

promote equal opportunity and prohibit discrimination.

PLEASE PRINT CLEARLY WHEN COMPLETING ALL SECTIONS OF THIS APPLICATION. THANK YOU.



It is preferred that the application be typed.
1. PERSONAL DATA

A) NAME AND ADDRESS:
Full Name: ________________________________ _________________________ ___

Last First M.I.


FORMER NAME (if applicable): ____________________________ EMPL ID(StudentAdmin): ______________

(UConn students only)

EMAIL ADDRESS: ____________________________________

(UConn students please use UConn email address)

PERMANENT HOME

ADDRESS: ___________________________________________ TELEPHONE (___) ________________

_____________________________________________________ PRINT CLEARLY

____________________________________ ______ _________

City State Zip code
SCHOOL/ TEMPORARY SCHOOL/ TEMPORARY/ CELL

ADDRESS: ___________________________________________ TELEPHONE (___) ________________

_____________________________________________________ PRINT CLEARLY

____________________________________ ______ _________

City State Zip code
**For your admission decision, which do you prefer as a mailing address? _______ Permanent Address

_______ School or Temporary Address


B) DATE OF BIRTH (for statistical purposes only): ____________________
C) GENDER (for statistical purposes only): ________________________
D) ETHNIC BACKGROUND (for statistical purposes only):

Ethnicity: Hispanic or Latino____ Not Hispanic or Latino____

Race (select all that apply from the following groups):

  • Asian

  • Hawaiian or Pacific Islander Native/American

  • American Indian or Alaskan Native/American

  • Black or African American

  • Puerto Rican

  • White Non-Hispanic American

  • Multiracial (please specify): _________________________

  • Other (please specify): ______________________________


E) Citizenship:

  • Native Born

  • Naturalized

  • Alien Permanent

  • Non-Resident (International Students) If you check this box, please complete part F.


F) International Students must provide the following information:

  1. Country of Birth: ________________________________________________________________

  2. Country of Citizenship: ___________________________________________________________

  3. Country of (Permanent) Residence: __________________________________________________

  4. Address in Home Country: _________________________________________________________

_______________________________________________________________________________


2. ADMISSION DATA
I have previously applied to the Department of Allied Health Sciences at the University of Connecticut. (Undergraduate or Certificate program).
___No ___ Yes If yes, list program and date(s) for which applications were filed: _________________________
____________________________________________________________________________________________
3. ACADEMIC DATA
A) If you are a current University of Connecticut student, please complete the information below; Otherwise proceed to item B.
Current Program/Plan: ________________________________________ Current Campus: ___________________

Anticipated date of graduation: _________________________________


B) List all educational institutions beyond high school level (in the order in which you attended them). Include OFFICIAL transcript for each institution attended.
Dates Attended Date Degree

Name of Institution Location From (Mo/Yr) To (Mo/Yr) Graduated Conferred

____________________________ ______________________ ________________________ ____________ ______________

____________________________ ______________________ ________________________ ____________ ______________

____________________________ ______________________ ________________________ ____________ ______________

____________________________ ______________________ ________________________ ____________ ______________


C) Applicants holding professional credentials and/or academic degrees. Provide copy of credential.

Professional licensure or certification held: _______________________________________________________


4. PAID WORK EXPERIENCE: List all work experience obtained in the past five years, with the most recent experience first.

Position, title, &

Place of employment City/State Dates Hrs/Wk Responsibilities

____________________________ ______________________ _______________ _________ __________________________

____________________________ ______________________ _______________ _________ __________________________

____________________________ ______________________ _______________ _________ __________________________

____________________________ ______________________ _______________ _________ __________________________

____________________________ ______________________ _______________ _________ __________________________


5. VOLUNTEER WORK EXPERIENCE: List all volunteer experience, with the most recent position first.
Place of experience City/State Dates Hrs/Wk Responsibilities

____________________________ ______________________ _______________ _________ __________________________

____________________________ ______________________ _______________ _________ __________________________

____________________________ ______________________ _______________ _________ __________________________

____________________________ ______________________ _______________ _________ __________________________

____________________________ ______________________ _______________ _________ __________________________


6. HONORS, EXTRACURRICULAR ACTIVITIES: List organizations, appointed or elected offices, scholarships, and honors received. Also include other activities and special interests that are not previously listed (i.e. community service).

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________


___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________
7. RECOMMENDATIONS:

Applicants to the Certificate programs in the Department of Allied Health Sciences must supply the admissions committee with at least two (2) but no more than three (3) letters of recommendation. One reference MUST be an academic reference (faculty/instructor). Recommendation Forms can be obtained on-line by following the link: http://www.cag.uconn.edu/ahs/ahs/documents/CertProgAppRecommendationForm.pdf. They should be sealed in an envelope then signed across the seal by the evaluator. It is preferable, when possible, to include sealed letters of recommendation with your application.

Note: Current Undergraduate DGS students are not required to submit recommendation letters.
8. PERSONAL STATEMENT: Applicants are required to submit a 500 word personal statement outlining their career goals as they relate to the program of application. Applicants applying to more than one program are required to submit a personal statement for each program. Guidelines to writing a personal statement can be obtained at the following link: http://www.cag.uconn.edu/ahs/ahs/admissions/PersonalStatementGuidelines.php.
9. TRANSCRIPTS: (Submit all transcripts that apply). Current Undergraduate DGS students are not required to submit transcripts. Refer to our web site at www.alliedhealth.uconn.edu for more information.

UCONN Transcript: Applicants must submit an unofficial (or official) University of Connecticut transcript if applying as a current or readmitted student.

Other Transcript: If applicable, applicants must provide an official transcript for all institutions attended whether or not a degree was granted. This transcript MUST be sent to the Department of Allied Health Sciences. Photocopies will not be accepted. Application is not complete without this documentation.

International Transcript: Applicants with education outside of the U.S. or Canada must submit transcripts of all coursework to a transcript evaluation agency for translation and evaluation for equivalency. International applicants should allow a lead time of six months or more to complete all requirements of entry into the United States. Refer to our web site at www.alliedhealth.uconn.edu for more information.
10. TOEFL SCORES: If you are not a native speaker of English, you must submit evidence of your proficiency in the English language. A Test of English as a Foreign Language (TOEFL) (www.ets.org) is required of all international applicants and U.S. citizens or permanent residents for whom English is not the primary language.
11. FINANCIAL DECLARATION: (International Applicants only). International applicants for the Certificate Programs must submit evidence of adequate financial support to cover the costs of study at the University of Connecticut before a Certificate of Eligibility (I-20 or DS-2019) will be issued.
Send completed application and supporting documentation to:

Department of Allied Health Sciences

Certificate Programs Admission

University of Connecticut

358 Mansfield Road

Storrs, CT 06269-1101



Certificate program application form rev. 11/2015



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