Application for Graduation - Adler School of Professional Psychology

GRADUATION PETITION**EFFECTIVE FALL 2010 TERM**PLEASE READ INSTRUCTIONS CAREFULLY BEFORE PROCEEDINGThe $140 graduation fee must be paid by ALL students. You must complete this form and pay the graduationfee, regardless of whether you intend to participate in the October commencement ceremony.This form triggers a series of processes that lead to the awarding of your degree. If this form is not submitted,your degree will not post and your diploma will not be ordered. Please see the academic calendar for duedates. Applications received after the deadline are subject to a $50.00 late fee.The Registrar’s office will perform a comprehensive audit of your academic records once this completed form,all relevant fees, and all grades are received.Financial Aid recipients must complete an exit interview and debt management seminar. Both items need to becompleted in order for you to receive your diploma. Please contact Financial Aid at financialaid@adler.edu toschedule an appointment.Student accounts must be paid in full at the time of program completion. Any outstanding balance willprevent the release of diploma(s), transcripts, letters of completion, and prevent the student from participatingin the commencement ceremony, etc. Contact the Student Account Manager’s Office atstudentaccounts@adler.edu for information about your student account or for payment options.If you apply for graduation and pay the fee but do not qualify to graduate at this time, you must reapply forgraduation. Your graduation fee will rollover, but you must submit a new application and check the appropriatebox in the “Payment Information” section. You must pay a graduation fee for EACH degree earned at Adler(i.e., if you earn a M.A. degree while working on your Psy.D, you must complete an application and pay thegraduation fee for the M.A. When you complete the Psy.D, you must complete another application and pay aseparate graduation fee – at the then prevailing rate – for the Psy.D). Psy.D students earning their MAalong the way must petition for their MA once their MA requirements are completed.Certificates completed in the same quarter as a M.A. or Psy.D WILL NOT be billed a separate fee; certificatescompleted in a different quarter from a M.A. or Psy.D, or completed on their own, DO require a separateapplication and full graduation fee.Diplomas are ordered at the end of every term. Please allow 8-12 weeks for the printing of your diploma. Alldiplomas will be mailed to the address we have on file. If you change your address after submitting thisapplication, you must notify the Registrar’s Office in writing and indicate if your diploma should bemailed to your new address.Psy.D. students may not use the title “doctor” and may not consider themselves finished with their degreeprogram until their internship is completed, all grades are posted, their final dissertation copies have beensubmitted to the PsyD department for binding and the fee paid, and all training paperwork has been received bythe Department of Training & Community Service.Students who wish to participate in the October commencement ceremony must complete all degreerequirements no later than the last day of the summer semester. Students enrolled in dissertation musthave their bound dissertation submitted to the PsyD department, no later than the end of the Summer I session.Students enrolled in internship must complete their internship requirements no later than August 31st.By submitting this application, you permit the Adler School of Professional Psychology to print your name in thecommencement program and to release your directory information to the Adler School Alumni Association.Your attendance at the commencement ceremony does not mean that your degree has been conferred andthat you have graduated from your program.Please retain this cover page and copy of this application for your records. Your signature indicatesyou have read and accept the information listed on this application. All pages of this petition, exceptthis cover page, must be submitted.

GRADUATION APPLICATIONEFFECTIVE FALL 2010 TERMSTUDENT INFORMATIONLast Name: _______________________________First Name: ________________________________Term and year in which ALL degree requirements will be completed:Spring __________ Summer __________ Fall __________DEGREE INFORMATION – please specify the degree(s) for which you are applying:Degrees:– Clinical Psychology – Counseling PsychologyM.A. – Marriage & Family Counseling– Counseling Psychology: Art Therapy– Counseling & Organizational Psychology – Police Psychology. – Gerontological CounselingM.A. – Counseling Psychology: Specialization in Forensic Psychology– Counseling Psychology: Specialization in Rehabilitation CounselingM.A. – Counseling Psychology: Specialization in Sport and Health PsychologyCertificates:Advanced Adlerian Psychotherapy- Group PsychotherapyConcentrations:l Hypnosis -Group PsychotherapyDoctoral Concentrations:Traumatic Stress PsychologyTherapyChild and Adolescent PsychologyPrimary Care PsychologyDIPLOMA INFORMATIONName as you would like it to appear on your diploma (please print):___________________________________________________________________________________________Psy.D students: Complete dissertation title (this title will be printed in the commencement program – please printlegibly):____________________________________________________________________________________________________________________________________________________________________________________Dissertation Chairperson: _____________________________________________________________________

EMPLOYMENT INFORMATIONAs you plan to graduate, have you secured employment? ___ Yes ___ Noa. Where have you secured employment?b. In your field of study?c. In what way does your new position incorporate Social Responsibility or Community Service?If not, how do you plan to pursue employment? What kinds of positions are you interested in finding?Did you gain employment at a practicum or internship placement you secured while at Adler School?Are you interested in applying for loan repayment or loan forgiveness programs? ___ Yes ___ NoAre you planning on sitting for licensure? ___ Yes ___ NoIf yes, which license and in which state?If not, what are your professional/career goals?COMMENCEMENT INFORMATIONOnly students who attend the commencement ceremony will receive their regalia and gift.Do you plan to attend the commencement ceremo(if no, proceed to “Payment Information”)How many guests will be in your party? _____________________Will YOU require any accommodations (e.g., stage ramp for wheelchair, ASL interpreter, etc.)?_________________________________________________________________________________Height: _______ Weight: _______ lbs Cap/Hat size: __________PAYMENT INFORMATIONGRADUATION FEE (PER DEGREE): $140 – REQUIRED OF ALL STUDENTS (ADD $50.00 LATE FEE IFSUBMITTING AFTER DEADLINE)please use the attached credit card authorization form)Student’s Signature: _________________________________Date Submitted: ________________Your signature indicates you have read and accept the information listed on this application.Office Use Only: Date received ___________ Payment included No account balance Audit completedApproved for graduation - staff initials & date___________