Application for Admission

Program to which you are applying:

Masters

Marriage & Family Therapy

I wish to begin the program in: (Check one and indicate year)

Term *

Year *

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: *

Home Phone:

Cell Phone:

Work Phone:

Email *

Preferred method of communication:

Email

Phone

Text

How did you first learn about Phillips Education Center? (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

Yes. When?Yes. When?

Have you ever attended Phillips or Campbellsville before?

No

Yes. When?Yes. When?

Have you ever been dismissed from a college or university? *

No

Yes. (If yes, please explain)Yes. (If yes, please explain)

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.

Name of Institution | Degree Earned | Date Degree 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 Phillips Education Center of 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: *

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

Resident Registration #:Resident Registration #:

Current Visa Held:Current Visa Held:

Type of Visa:Type of Visa:

Gender *

Female

Male

Marital Status *

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

Marriage and Family Therapy