Application For Admission Enrollment Services Office Application Process Application For Admission Cost and Financial Aid Federal Direct Stafford Loan Federal Direct Graduate PLUS Loan Marriage and Family Therapy Application for Admission Application for Admission If you are human, leave this field blank. Program to which you are applying: Master of Marriage & Family Therapy I wish to begin the program in: (Select a term and year please) * August/Fall 2020 January/Spring 2021 I prefer to have my full cohort day on: * Weekdays only Saturdays only No preference Will you be requesting transfer of credits (units must be graduate level)? If yes, please complete the Transfer of Credit Request Form and submit it along with your supporting documents. No Yes Personal Information: First Name: * Middle Name: Last Name: * Previous Name(s): Nickname: Social Security Number: Street Address: * Apt/ Suite/ Other: City: * State: * Zip Code: * Country: * Primary Phone Number: * Secondary Phone Number: Email * Preferred method of communication: Email Phone Text How did you first learn about Phillips Graduate Institute's MFT Program? (Please be specific) * If you were referred by a current student, faculty member, staff member, or graduate of Phillips, please list that person’s name here: Have you ever attended Phillips or Campbellsville before? No Have you ever attended Phillips or Campbellsville before? No Have you ever been dismissed from a college or university? * No Educational & Professional Information: List in chronological order all colleges attended regardless of whether courses were completed for credit (use additional paper if necessary). It is your responsibility to request official transcripts from all previously attended colleges or universities to be sent directly from each institution to the Enrollment Services Office. In addition, students with international credentials must submit an official translation from an approved agency. 1. Name of Institution * Degree Earned * Date Earned/Anticipated * 2. Name of Institution Degree Earned Date Earned/Anticipated 3. Name of Institution Degree Earned Date Earned/Anticipated 4. Name of Institution Degree Earned Date Earned/Anticipated 5. Name of Institution Degree Earned Date Earned/Anticipated List any honors, awards and scholarships you have received, any positions you have held in the community or professional life, and any publications in your name. List the learned, honor, or professional societies in which you have membership, with their beginning date. General Information: Please note: Applications for admission to the educational program offered by Campbellsville University are evaluated without regard to or discrimination based upon race, color, sex, religion, age, national ancestry or origin, sexual orientation, or physical or mental disability. Information on sex, age, ethnic origin, and citizenship status is for compliance reports in connection with federal regulations pursuant to the Civil Rights Act of 1964, Executive Order 11246 as amended by Executive Order 11375 and Title IX of the Education Amendments of 1972 and Part 86.45 C.F.R., and will not be used to discriminate in admission to or participation in any of the educational program offered by Campbellsville University Status of Employment: * Full Time Part Time Self-Employed Unemployed Retired Are you interested in Financial Aid? * No Yes Do you qualify for Veterans Benefits? * No Yes Date of Birth * Place of Birth: * Country of Citizenship: * Citizenship Status: * United States Citizen Resident Alien Non-resident Alien Gender * Female Male Marital Status * Divorced Living with Committed Partner Married Single Widowed Ethnic Survey (Part A). Do you consider yourself Hispanic/Latino? Yes (Continue to signature) No (Continue to Part B) Ethnic Survey (Part B) American Indian or Native Alaskan Asian Black or African American Native Hawaiian or Pacific Islander White or Caucasian Multi-Racial – 2 or more races Prefer not to answer Non-resident Alien (International Students Only) 1.) I understand that if admitted to Campbellsville University, I must comply with all rules, regulations, and policies of Campbellsville University. I understand that admission to and matriculation in the program in no manner guarantees successful completion of the program and the awarding of a degree. I hereby affirm that the information supplied by me on this application form is true and correct to the best of my knowledge and understand that omissions or falsification may result in withdrawal of acceptance. 2.) I understand the training for which I hereby make application will not in itself qualify me for the California license as a Marriage and Family Therapist (MFT). Programs at Campbellsville satisfy only the minimum education requirements for the aforementioned licenses, registrations and/or credentials. 3.) It is further recognized by the undersigned that initial acceptance into the program does not obligate Campbellsville University, nor any of its representatives, to maintain any student in the program if said student is found to be unfit for the program by any reason of personality, academic or attitudinal characteristics, or because of unmet financial obligations. 4.) Three-Day Full Refund Period: California State Administrative Code Section 18809 (a) (4) states that if the enrollee cancels within three (3) working days after registering, provided no classes have been attended or lessons completed, all tuition monies paid will be refunded. Fees are not refundable. 5.) Since this is a program which involves the development of professional potential in interpersonal relationships, I understand that I may be required to attend an interview prior to enrollment in the program. 6.) Any questions or problems concerning this institution which have not been satisfactorily answered or resolved by the institution should be directed to the Superintendent of Public Instruction, State Department of Education, Sacramento, California 95814. Signature: Date Submit
