Application for Post-Graduate Play Therapy Certification Program
Please complete online application and submit. Mail application fee of $75.00 to Temple University, Harrisburg Campus, 234 Strawberry Square, Harrisburg, PA 17101 Attention: Dr. Laura Dimino. Please also arrange to send an official copy of academic transcripts and copy of your resume/cv via mail to the same address, or via email to pthbg@temple.edu. Temple will require your social security number at a later time prior to complete registration. Email: pthbg@temple.edu with any questions.
1.) Full Legal Name
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2.) Prior Name(s) used (if any)
Your answer
3.) Country of Citizenship
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4.) Email address
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5.) Phone number
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4.) Gender
5.) Date of Birth (Month/Day/Year)
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6.) Ethnicity
7.) Indicate the race(s) you consider yourself:
8.) Permanent Home Address - street, city, state, zip code
Your answer
9.) Mailing address (if different) - street, city, state, zip code
Your answer
10.) Chronological List of ALL degrees received, and the College or University awarding the degree (including Temple University, if applicable)
Your answer
11.) Semester Applying for:
12.) Have you previously applied to Temple?
13.) Are you currently a Temple Student? If yes, at which campus and in which program?
Your answer
13 a.) If you are or have been a Temple student, what is your 9- digit Temple ID Number?
Your answer
14 a.) Were you ever found responsible for a disciplinary violation at any college or university you attended, whether related to academic or behavioral misconduct, that resulted in your probation, suspension, or dismissal from that institution?
b.) Have you ever been convicted of a felony?
c.) If you answered "yes" to either "a" or "b" please provide an explanation of the incident(s), including date(s) and terms of resolution, such as fine, suspension, probation, etc.
Your answer
15.) Work Experience (list positions)
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16.) Activities in Professional, Community, and Collegiate Organizations
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17.) Publications, Theses, Awards, and Creative Work
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18.) Statement of Professional Plans or Goals (required of ALL applicants): Please explain how this program fits in with your career and professional goals.
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19.) Statement of Exceptional Circumstance (optional): Present any personal information that may assist the admissions committee in interpreting and evaluating your academic history and/or your academic credentials.
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20.) Statement of Residence (Required of ALL applicants)
Country of Citizenship
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Native Language
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US Permanent Resident?
Type of U.S. Visa (if applicable)
U.S. State of Legal Residence
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County
Your answer
If you claim Pennsylvania residency, will you have resided in Pennsylvania for 12 consecutive months preceding entry into Temple?
If you claim Pennsylvania residency, have you been a student any time during the past 12 months?
If yes, what college or university did you attend and where?
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If currently in military service, are you assigned to active duty at a military installation in Pennsylvania?
If you are related to a military person assigned to active duty in Pennsylvania, indicate whether you are a:
If you are a veteran and would like to receive information on support services for veterans, please check this box:
Residency: Please retype the following statement filling in the blanks. I am now, and have been since, --------------(month/year) a legal resident of the state of ------------------.
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Signature: Please initial and date to serve as your electronic signature.
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