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Supplemental Application for Admission to the UMKC Clinical Psychology PhD Program (Health Emphasis)
Directions: Please complete this application in your word processor by typing in the form fields provided. Print and sign the completed form for
submission.
Name:
SSN#:
Telephone:
E-mail Address:
Applying for:
Admission to Clinical Psychology PhD Program and Graduate Assistantship funding
Admission to Clinical Psychology PhD Program only (with no Graduate Assistantship)
Current Degree(s):
Bachelor’s in
Completed mm/yy
Anticipated mm/yy
Master’s in
Completed on mm/yy
Anticipated on mm/yy
Other, specify:
Completed on mm/yy
Anticipated on mm/yy
If you are currently enrolled in college, or plan to complete additional coursework prior to admission to graduate school, please indicate this
below.
Currently Plan to
Course Title & Number Enrolled Take
List the names and addresses of the three people from whom you have requested recommendations.
Recommender Address
Name:
Title:
Telephone:
Name:
Title:
Telephone:
Name:
Title:
Telephone:
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Please provide the requested information for Items 1-6 below. The form will expand to incorporate your answers with extra pages, if necessary.
If you have more entries for an item than are allowed by the form, you may unprotect the document (go to “Tools” and select “Unprotect
Document”) to insert additional copies of that headings provided and then make additional entries. If you have no information relevant to an
item, please check the box labeled “None” after the numbered item.
Place the Information requested on this form; do not refer the reader to your CV or resume.
1) List any previous clinical work or experience, beginning with your most recent position. For each entry, please indicate whether it
was a volunteer or employed position. Describe your specific role and responsibilities for each experience.
None
Position/Title:
Location:
Supervisors(s):
Dates:
Responsibilities/Experiences:
Position/Title:
Location:
Supervisors(s):
Dates:
Responsibilities/Experiences:
Position/Title:
Location:
Supervisors(s):
Dates:
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Location:
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Position/Title:
Location:
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List any previous research work or experience, beginning with your most recent experience. For each Entry, please indicate
whether it was related to a student research experience (e.g., for academic credit, student project, honor’s thesis, etc.) or a formal
research position (e.g., working as a research assistant). Describe your specific role and responsibilities for each experience.
None
Position/Title:
Student experience / Research position
Research Project Title(s):
Location:
Supervisor(s):
Dates:
Responsibilities/Experiences:
Position/Title:
Student experience / Research position
Research Project Title(s):
Location:
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Dates:
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Student experience / Research position
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Location:
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Location:
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Position/Title:
Student experience / Research position
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2) Using APA format and beginning with the most recent, please list any professional publications or presentations. You may submit
preprints/reprints, if any, with your application.
None
Publications:
Presentations:
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3) Please provide any information pertaining to your professional identity and professional involvement (e.g., service activities,
professional organization memberships, conference attendance, continuing education activities, etc.).
None
Activity:
Dates:
Description:
Activity:
Dates:
Description:
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4) Please provide a brief statement of your career/professional goals, your current educational goals, and how these goals relate to our
program curriculum and faculty interests.
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5) Please provide a personal statement that describes you and your reasons for applying to this program.
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Optional: If you wish to include any additional information that might be relevant to evaluating your potential in this graduate program,
please do so here.
Please print, sign, and date your completed supplemental application. Submit the completed form directly to the UMKC Psychology Department
address provided on our webpage.
I certify that the information provided within this application is true, correct and complete to the best of my knowledge. I understand that any
misstatement or omission in this application will void the application.
Applicant’s Signature Date
The University of Missouri-Kansas City is an equal opportunity/affirmative action institution.
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