PRELIMINARY APPLICATION
OHIO INTERNSHIP GRADUATE PROGRAM IN SPEECH LANGUAGE PATHOLOGY

Start Date: September, 2011

Name: (Last) (First)
Address:
City: State: Zip Code:
County of Residence:
Telephone Number: (H) (W) (Cell)
E-mail: FAX:
A school district may recruit and pledge financial support for an Intern applicant. Is this application supported by a specific Ohio School District?
If yes, which school district?
Name of Administrator: Title:

















Education

College/University Degree Major GPA Date of Graduation










GRE: Verbal Score Quantitative Score Analytic Score
Date of Test
If no GRE Scores are available, when do you plan to take the test?






Employment

Current Employer:
Position:
Address: City: State: Zip:
Number of years with Current Employer:








Professional Intentions: What circumstances have led you to pursue the Ohio Internship Graduate Program in Speech Language Pathology?

I understand that if I am accepted into the Internship Graduate Program, I will:

  • Complete intense on-campus graduate coursework and required practicum during the first year of program.
  • Accept internship district assignment determined by the Ohio Department of Education, OMNIE, and university.
  • Commit to a total of 4 years of school district participation, depending on university requirement of combination 1-2 years of internship and 2-3 years of district employment following graduate program completion.
  • Understand failure to complete internship or district employment commitment will require re-payment of OMNIE/university student funding.

 

Electronic Signature: Date:


Preliminary Application deadline: January 1, 2011

or FAX to Nada Allender @ 330-699-4146.

Within 48 hours, you will receive an e-mail response to your application. If you do not receive the response, send notification to nada@ameritech.net.

Hard copy can be mailed to:

Nada Allender, M.A., CCC-SLP
OMNIE Project Coordinator
1898 White Chapel Cir. NW
Uniontown, OH 44685