University of Utah Gerontology
Program
Graduate Program Application for Admission to Graduate
Study
Master of Science in Gerontology
$20.00 processing fee
required.
Note: This application form is part of the application packet that must submitted to the Gerontology Program. All applicants must also apply to the Graduate School in order to make the application process complete. The Graduate School requires a separate form; this form can be requested directly from the Graduate School Admissions Office (801) 581-7283 or from their web site: http://www.utah.edu/graduate_school/index.html or from the Gerontology Program: (801) 581-8198. All applicants must submit a separate Goal Statement (see instructions below) and provide three letters of reference. Questions ? Call: Scott Wright, Director of Graduate Studies: 801-585-9542
Please type or print:
Date: _________________
Name: ___________________________ uNID ________________________________________
Date GRE Exam taken (or registered for);
___________________________________
(FOR GRE
TEST, CENTER ON AGING CODE IS 2207)
Current Address: _____________________________________________________________
Permanent Address: ___________________________________________________________
Telephone: (H) ______________________________ (W) _____________________________
Are you a legal resident of Utah ? Yes ______ No ______
Semester Term
applying for: Summer __________ Autumn _________ Year: ____________
Semester/Year expected to complete: _____________________________
Specialization Track
Program choice:
Long-Term Care and Aging
Services Administration _____
Research & Evaluation
_______
Educational Gerontology & Lifelong learning _______
Geriatric
Care Management _______
Other: ______ (specify focus:
__________________________________________)
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Educational Experience (begin with most recent, include all colleges, universities)
List School, City/State, Dates Attended, Major, and Degree Held/Expected, on each line:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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Professional Work Experience (list all relevant, beginning with most recent, add pages in necessary)
List employer (name & address), dates, Title of position, and duties/responsibilities, on each line:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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Research Experience (publications, presentations; you may submit vita/resume in lieu of listing)
List title, where presented, dates, where published, on each line:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
References will be submitted by (provide letters of support) (list at least three):
List name and professional role/relationship on each line:
____________________________________________________________
____________________________________________________________
____________________________________________________________
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-
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Affirmative Action: the following information is requested for Affirmative Action and Recruitment purposes and not required as a condition of acceptance.
Male: _____ Female: ______
U.S. Citizen: Yes ________ No _________ If no,
type of visa: ___________________
If no, please contact University of Utah
International Student Services, 250 Student Services Building, SLC, UT.
84112
Handicapped: Yes _____ No _______
Ethnic Origin:
American
Indian or Alaskan Native _____
Asian or Pacific Islander ______
Black, not
of Hispanic Origin ______
Hispanic (any origin) ______
White, not of
Hispanic Origin _______
The University of Utah is an Affirmative Action/Equal Opportunity Employer and, as such, is fully committed to nondiscrimination and equal opportunity in, a) all programs and activities, including but not limited to student admissions and student financial assistance; and b) faculty and staff employment, including but not limited to recruitment, compensation, and advancement without regard to age, race, color, religion, sex, national origin, or status as a handicapped individual, disabled veteran, or veteran of the Vietnam era. Evidence of practices which or not consistent with the policy should be reported to the Office of the President of the University of Utah.
Recruitment
In order to improve recruitment efforts, we would like to know how you first
learned of the University of Utah Gerontology Master's program. (check all that
apply):
____ word of mouth (friend, co-worker, etc.)
____Personal contact
with someone in Center on Aging
____Newsletters
____Open
House
____Gerontology courses
____ Web surfing (search engine or random
linking)
____ Other, please explain
_______________________________________
GOAL STATEMENT
All applicants must submit a 5-page typewritten GOAL STATEMENT in addition to the Center on Aging Graduate application form. The GOAL STATEMENT is considered a very important part of the application process by the Center on Aging Master's Degree Admissions Committee. Please state your goals and objectives in relation to the Master's Degree Program; Why is a Master's Degree in Gerontology important to you? Why is this University of Utah Gerontology Master's program of interest to you ? Please be specific and indicate the "match" between your goals and the Gerontology Program faculty and academic resources. Questions? call (801) 581-9542 (phone).