Certificate programs application
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- Program of Application: ( IMPORTANT: please read all instructions prior to completing this section )
- F) International Students must provide the following information
- Send completed application and supporting documentation to
| UNIVERSITY OF CONNECTICUT
College of Agriculture, Health and Natural Resources DEPARTMENT OF ALLIED HEALTH SCIENCES
CERTIFICATE PROGRAMS APPLICATIONGeneral 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.
_____ 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:
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
ADDRESS: ___________________________________________ TELEPHONE (___) ________________ _____________________________________________________ PRINT CLEARLY ____________________________________ ______ _________ City State Zip code
_______ 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):
E) Citizenship:
F) International Students must provide the following information:
_______________________________________________________________________________ 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). ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________
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.
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 Directory: admissions admissions -> Duke University Tour Guide Training Manual admissions -> Job Description Graduate Research Assistant Economic Research Institute of Erie Sam and Irene Black School of Business Penn State Erie admissions -> Year 9 2014/15 johnson library sevenoaks school year 9 suggested reading list admissions -> Supreme Court of the United States admissions -> Grade 9 english: Honors admissions -> After school program admissions -> Department of the air force admissions -> External Funding Resources Scholarships, Grants, Fellowships and More admissions -> Instructions for uhcl counseling Program Application admissions -> Smc journalism Regular Admissions 2015 List of candidates selected for Interview Download 32.87 Kb. Share with your friends:
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