Dietetic Internship Program Application - Download Now DOC

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					                            University of Washington
           Graduate Coordinated Program in Dietetics (GCPD) Application
Note: Prospective students completing this application are interested in receiving the training necessary to sit for the Registered
Dietitian (RD) exam and must also apply to the nutritional sciences program for a degree (MS/MPH/PhD). Applications must be typed &
                                      th
submitted electronically by January 15 for consideration. This is a hard deadline and late applications will not be accepted. Submit the
GCPD Application along with the Nutritional Sciences application via the Graduate School Website. Name this file:
Lastname_GCPD_year

There are two options for prospective students to the University of Washington’s GCPD, please indicate which track you
are applying for:

          Track        Description
                       Students who need both the coursework and the supervised practice. These students are applying
          #1:          for the Graduate Program in Nutritional Sciences and the GCPD for both the dietetic coursework
 _____                 and the supervised practice.
                       Students who have already completed their dietetic coursework from an accredited Didactic
                       Program in Dietetics (DPD) and have received their DPD verification form or will have the form
          #2:
                       when they are enrolled at the UW. These students are applying for the Graduate Program in
 _____                 Nutritional Sciences and the GCPD for the supervised practice.


Section A: All Applicants
                                                                                                      Date

Name
                             (Last)                                            (First)                            (Middle or Maiden)



  Present Address

                                                                        (Street)                                                 (Apt #)
                                                                                                                  xxx-xxx-xxxx
                                               (City)                          (State)   (Zip Code)                    (Phone)



Permanent Address
      (If different)
                                                                        (Street)                                                 (Apt #)


                                               (City)                          (State)   (Zip Code)                    (Phone)




                                              Cell Phone Number




                                                E-mail address                                          Social Security Number




                                      Actual or Expected Date (Month/Year)                    Actual or Expected Date (Month/Year)
                                        Baccalaureate Degree conferred                   DPD Course requirements completed (Track 2 only)



                                                                                                        Expiration Date:
Foreign Applicants: Designate Immigration Status
Page 1 of 6                                                                                                  Revised September 2012
Honors and/or extracurricular activities after beginning college: List organizations, appointed or elected offices held,
scholarships, honors, and certifications received. Include dates for honors




Professional Organization Memberships: List professional organizations of which you are a member.




Work experiences in the past five (5) years: List all experiences, including volunteer, beginning with the most recent.
Indicate if the experience was paid, volunteer or part of a practicum/field experience associated with a college course.
Briefly describe key responsibilities. When indicating the amount of hours, use hrs/wk for reoccurring work and volunteer
experiences and total hours for limited time volunteer and practicum/field experiences. Use additional pages as needed.
(Note: if you have professional dietetic work experience from over five years ago, you may include it.)


                                                               Start and End Dates        Hrs/Wk         Paid, Volunteer,
     Name of Employer / Organization      Position Title
                                                                  (Month/Year)        or Total Hours      or Practicum
1.
                                                                                     Email:
Supervisor’s Name and Title:
                                                                                     Phone:
Key Responsibilities:




2.
                                                                                     Email:
Supervisor’s Name and Title:
                                                                                     Phone:
Key Responsibilities:




Page 2 of 6                                                                                   Revised September 2012
3.
                               Email:
Supervisor’s Name and Title:
                               Phone:
Key Responsibilities:




4.
                               Email:
Supervisor’s Name and Title:
                               Phone:
Key Responsibilities:




5.
                               Email:
Supervisor’s Name and Title:
                               Phone:
Key Responsibilities:




6.
                               Email:
Supervisor’s Name and Title:
                               Phone:
Key Responsibilities:




7.
                               Email:
Supervisor’s Name and Title:
                               Phone:
Key Responsibilities:




8.
                               Email:
Supervisor’s Name and Title:
                               Phone:
Key Responsibilities:




9.
                               Email:
Supervisor’s Name and Title:
                               Phone:
Key Responsibilities:




Page 3 of 6                             Revised September 2012
GOAL STATEMENT: In addition to the goal statement you provided to the Nutritional Sciences Program please include
an additional statement regarding your qualifications for the Graduate Coordinated Program in Dietetics. Insert no more
than two double-spaced typewritten pages below.


     1. As student in a graduate level dietetics program you will receive training to apply evidence based knowledge to
        clinical and public health practice. Please explain how you envision using this knowledge to become a leader in
        dietetics.




_________________________________________________________________________________________________

I certify the information I have provided in this application is true and accurate and recognize any false or incorrect statements made herein will be
grounds for my dismissal from the program. I understand that track 2 students must provide an original copy of a signed Verification Statement
substantiating completion of academic requirements prior to start date of program.




                                         Date                                                           Signature




Page 4 of 6                                                                                                            Revised September 2012
Section B: Track #1 Only

Students applying under track #1 who previously have not completed a DPD need to provide information on their GPA for
the prerequisites to Nutritional Sciences and the GCPD which are: English, human nutrition, microbiology, psychology,
general chemistry, organic chemistry, biochemistry, human physiology and foods (such as Molecular Gastronomy or Food
Preparation). If a course has not been completed, indicate INC in the No. of Credits column.

                              Course
                                                           Course                                     No. of    Grade
College or University         Prefix &                                                  Term & Year
                                                            Title                                     Credits   Earned
                                No.




Grade Point Average:                                           Overall
                                                            Undergraduate
                                                                GPA




Page 5 of 6                                                                             Revised September 2012
Section C:         Track #2 Only
Include all courses required to meet Didactic Program in Dietetic (DPD) requirements at your college or university. If a
course has not been completed, indicate INC in the No. of Credits column. Use additional pages as needed.

                                Course
                                                               Course                                      No. of    Grade
College or University           Prefix &                                                     Term & Year
                                                                Title                                      Credits   Earned
                                  No.




Grade Point Average:                                                       Overall
                                                                        Undergraduate
                                                                            GPA




Page 6 of 6                                                                                  Revised September 2012

				
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