Graduate On-line Application Form

Office of Graduate Admissions 263 Alden Street Springfield, MA 01109-3797

1. Name:

Last Name:

First Name:

Middle Initial:

Date: 07/24/2008

2. Home Address:

Street:

City/Town:

State: Choose one AK AL APO-AA APO-AE APO-AP AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY

Zip Code:

Telephone:	Home:	School or Business:
	Fax:	E-Mail:

Present Address (to which correspondence is to be sent):

Street:	City/Town:	State:	Zip Code:
		Choose one AK AL APO-AA APO-AE APO-AP AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY

3. U.S. Citizen: Yes No

Permanent Resident: Yes No

Social Security Number:

If not U.S. citizen, please indicate country of present citizenship:
4. Gender: Male Female	Please indicate any other last names used:

5. Date of Birth (optional):
6. Ethnic Background (optional):	Choose one Black or African-American Caucasian (White) Mexican_American or Chicano Native American Asian-American Other Black Other Hispanic or Latin American Puerto Rican Other
7. Please indicate whether you wish to receive Springfield College housing information:	Yes No
8. What most influenced your application for admission? Please check only one.	Choose one Alumnus Campus Visit Counselor/Faculty Advisor Current Student Graduate School Publication Other Reputation of Program
9. Intended Date of Entry:

10. Please indicate your choice of degree, academic area of study, and, if appropriate, your intended program/concentration*: program list updated: 09/16/2004

Master's Degree	Master's Program: Choose One *Art Therapy *Education Education--Evening Graduate Program *Exercise Science & Sport Studies *Health Care Management Health Studies *Occupational Therapy *Occupational Therapy--Evening Graduate Program *Physical Education Physical Education--Evening Graduate Program Physician Assistant *Psychology & Counseling Psychology & Counseling--Evening Graduate Program *Rehabilitiation Counseling & Services Rehabilitation Counseling and Services--Evening Graduate Program *Social Work *Sport Management & Recreation
	*REQUIRED - Select your intended program/concentration within the area of study checked above:
Master's Concentration	Choose One ART THERAPY/Clinical Art Therapy ART THERAPY/Studio Art Therapy EDUCATION/Education Administration EDUCATION/Educational Studies EDUCATION/Educational Studies-Early Childhood Education EDUCATION/Educational Studies-Elementary Education EDUCATION/Educational Studies-Secondary Education EDUCATION/Educational Studies-Students with Moderate Disabilities EXERCISE SCIENCE AND SPORT STUDIES/Athletic Training EXERCISE SCIENCE AND SPORT STUDIES/Exercise Physiology/Clinical Track EXERCISE SCIENCE AND SPORT STUDIES/Exercise Physiology/Science and Research Track EXERCISE SCIENCE AND SPORT STUDIES/Health Promotion and Disease Prevention EXERCISE SCIENCE AND SPORT STUDIES/Sport Psychology EXERCISE SCIENCE AND SPORT STUDIES/Strength and Conditioning HEALTHCARE MANAGEMENT/Long Term Care Facilities HEALTH STUDIES/Health Education Teacher Licensure OCCUPATIONAL THERAPY – Entry Level Masters OCCUPATIONAL THERAPY – Post Professional Program PHYSICAL EDUCATION/Adapted Physical Education PHYSICAL EDUCATION/Advanced Level coaching PHYSICAL EDUCATION/Athletic Administration PHYSICAL EDUCATION/Physical Education Teacher Licensure PHYSICAL EDUCATION/Physical Education Teaching-Clinical PSYCHOLOGY AND COUNSELING/Athletic Counseling PSYCHOLOGY AND COUNSELING/Industrial/Organizational Psychology PSYCHOLOGY AND COUNSELING/Marriage and Family Therapy PSYCHOLOGY AND COUNSELING/Mental Health Counseling PSYCHOLOGY AND COUNSELING/School Counseling and Guidance PSYCHOLOGY AND COUNSELING/Student Personnel Administration REHABILITATION COUNSELING AND SERVICES/General Rehabilitation Counseling REHABILITATION COUNSELING AND SERVICES/Special Services-Disability Studies REHABILITATION COUNSELING AND SERVICES/Substance Abuse Counseling REHABILITATION COUNSELING AND SERVICES/Psychiatric Rehab & Substance Abuse Counseling REHABILITATION COUNSELING AND SERVICES/Pediatric Developmental Disabilities REHABILITATION COUNSELING AND SERVICES/Counseling for Deaf & Hard of Hearing SPORT MANAGEMENT AND RECREATION/Recreation Management SPORT MANAGEMENT AND RECREATION/Sport Management SPORT MANAGEMENT AND RECREATION/Therapeutic Recreation Management SPORT MANAGEMENT AND RECREATION/Therapeutic Recreation Management/Child-Life Specialist Track SOCIAL WORK/Advanced Standing-Weekday SOCIAL WORK/Advanced Standing-Weekend SOCIAL WORK/Combined MSW/JD Program - "Weekdays Only" SOCIAL WORK/Regular Weekday Program SOCIAL WORK/Regular Weekend Program concentration list updated: 11/26/2007

Certificate of Advanced Graduate Study (CAGS)	Certificate of Advanced Graduate Study Program: Choose One Art Therapy Education Occupational Therapy Physical Education Psychology and Counseling Rehabilitation Counseling and Services
	*Indicate your intended program/concentration within area of study checked above:
Certificate of Advanced Graduate Study	Choose One ART THERAPY/Clinical Art Therapy ART THERAPY/Studio Art Therapy EDUCATION/Education Administration EDUCATION/Educational Studies EDUCATION/Educational Studies-Early Childhood Education EDUCATION/Educational Studies-Elementary Education EDUCATION/Educational Studies-Secondary Education EDUCATION/Educational Studies-Students with Moderate Disabilities HEALTH STUDIES/Health Education Teacher Licensure PHYSICAL EDUCATION/Physical Education Teacher Licensure PHYSICAL EDUCATION/Physical Education Teaching-Clinical PSYCHOLOGY AND COUNSELING/Athletic Counseling PSYCHOLOGY AND COUNSELING/General Counseling PSYCHOLOGY AND COUNSELING/Industrial/Organizational Psychology PSYCHOLOGY AND COUNSELING/Marriage and Family Therapy PSYCHOLOGY AND COUNSELING/Mental Health Counseling PSYCHOLOGY AND COUNSELING/School Counseling and Guidance PSYCHOLOGY AND COUNSELING/Student Personnel Administration REHABILITATION COUNSELING AND SERVICES/General Rehabilitation Counseling REHABILITATION COUNSELING AND SERVICES/Special Services-Disability Studies REHABILITATION COUNSELING AND SERVICES/Substance Abuse Counseling REHABILITATION COUNSELING AND SERVICES/Psychiatric Rehab & Substance Abuse Counseling REHABILITATION COUNSELING AND SERVICES/Pediatric Developmental Disabilities REHABILITATION COUNSELING AND SERVICES/Counseling for Deaf & Hard of Hearing
Doctor of Physical Education Doctor of Physical Therapy	Doctoral Programs: Choose One PHYSICAL EDUCATION/Exercise Physiology PHYSICAL EDUCATION/Sport Psychology PHYSICAL EDUCATION/with a Specialization in Teaching & Administration PHYSICAL THERAPY

11. Undergraduate College or University:
Graduation Date:	Major Field:	Degree:

12. Graduate College or University:
Graduation Date:	Major Field:	Degree:

13. Please list other collegiate institutions attended and dates of attendance:

College#1:	Date:	College#2:	Date:
College#3:	Date:	College#4:	Date:
College#5:	Date:	College#6:	Date:

14. Please select three people who can comment on your interest in graduate study at Springfield College and your ability, potential, and readiness for the graduate program you have selected. We suggest you seek references from faculty members, advisors, internship supervisors, current or past employers, colleagues, or alumni of Springfield College. Social Work applicants should submit professional supervisors' or academic references only. (Note: If you are currently enrolled in a master's degree at Springfield College, only two references from faculty with whom you took classes at Springfield will be needed.)

	Name:		Relationship to Applicant:
#1		#1
#2		#2
#3		#3