Preliminary Applicationfor The University of Akron (UA) and University of Cincinnati (UC) Distance Learning CollaborativeGraduate Program In Speech LanguagePathology

Start Date: January 2012

Although coursework will be completed through several universities across the state, applicants will apply to either the University of Akron or the University of Cincinnati for enrollment in the master’s degree program. You may indicate your preference for enrollment below, but in order to balance the number of applicants at each university, applicants may be assigned toeither UA or UC. Following the review of your preliminary application, you will receive specific instructions about how to apply to the university. Questions can be addressed to Mrs. Kelly Wade at UA, () or Mrs. Sally Disney at UC, ().

I prefer to enroll at: _____ University of Akron _____ University of Cincinnati

Name: (Last) (First)
Address:
City: State: Zip Code:
County of Residence:
Telephone Number: (H) (W) (Cell)
E-mail: FAX:

EDUCATION

College/University / Degree / Major / GPA / Date of Graduation
GRE: Verbal Score Quantitative Score Analytic Score
Date of Test (must be 5 years or sooner)
If no GRE Scores are available, when do you plan to take the test?

PRE-REQUISITE COURSEWORK

If your undergraduate degree is not in Communication Sciences and Disorders there will be 4 required leveling courses in CommunicationSciences and Disorders. In addition there are 4required undergraduate courses in math, physical, biological and social/behavioralsciences.

LEVELING CLASSES

Course / University / Semester/quarter Completed
Anatomy & Physiology of Voice & SpeechProduction – UC OR
Introduction to Speech Science - OSU
Audiology I (Anatomy of the ear) – UC ORIntroduction to Hearing Science – OSU
Language Science and Acquisition – UA OR Language Acquisition – OSU
Audiology II (Assessment) – UC OR Introduction to Audiology – OSU

EMPLOYMENT

Current Employer:
Position:
Address: City: State: Zip:
Full or part time?

It is imperative that you have the flexibility in your employment during the weekdays in order to complete clinical practicum requirements. A minimum of 400 clock hours are required working under a licensed and certified speech-language pathologist in school and health care settings. The number of hours per week spent in practicum increases as you proceed through the program.

Please write a brief statement about why you think you would make a successful distance learner and what circumstances have led you to pursue a Graduate Program in Speech Language Pathology.

Please return this form by email or fax to your preferred school no later than August 15, 2011.

Kelly Wade: or fax, 330-972-7884 at the University of Akron

or

Sally Disney: r fax: 513-558-8500 at the University of Cincinnati

In order to enroll in required leveling courses in the fall of 2011, return this form ASAP.