Msltprac Supplementary Application Form 2015

SCHOOL OF PSYCHOLOGY SUPPLEMENTARY APPLICATION FORM FOR 2015 ENTRY FOR MSLTPrac PROGRAMME (Applications close 1st November 2014– please note late applications will not be accepted) All responses must be completed in the spaces provided. Handwritten applications will not be considered. Please do not attach a cv. Your application form is confidential to the Selection Committee and will be shredded if you are not selected into the programme. Please read our ‘Information for Prospective Students’ document before completing this application form. Please send your completed form with a passport sized photograph to The Speech Science Selection Committee, School of Psychology (Tāmaki Campus), The University of Auckland, Private Bag 92019, Auckland. At the same time as applying to the School of Psychology, you need to apply on Student Services online by logging onto www.auckland.ac.nz and click on Apply Now. You need to do this by 1st November as after this date applications are closed online.

Full Name Permanent Home Address

University of Auckland ID Phone Numbers Home: Mobile: Work: Email Address Date of Birth Ethnic Group Gender Male  Female  If you are going to be overseas at the time of interviews (late November early December) please give us your skype address

Referees The University of Auckland also requests your permission for members of the Selection Committee for the Master of Speech Language Therapy Practice programme to contact your referees and any lecturing staff from programmes you have completed in your last year of study. This would be to ask further information about you, relevant for the purposes of selection into the programme.

I agree that members of the Selection Committee may speak to my referees and other academic staff for the purposes described Signed: Date:

List the name, address, phone and email contact information for each of your referees. (Two referees are required, but you are welcome to use a third referee if you wish). Note: Your referees should be able to comment on all the relevant areas mentioned in the Confidential Letter of Reference form. If one referee cannot comment on your skills and experience in a particular area, you should ensure your other referee can comment on this topic. References will not be accepted from family members or friends. Please ensure your referees sign the copy of their reference or they will not be accepted. References should be received by Speech Science by 1 November. Name Address Phone and Email contact 1 Ph: Email: 2. Ph: Email: 3. Ph: Email: Code of Ethics: MSLTPrac students are required to comply with the Code of Ethics of the New Zealand Speech- Language Therapists’ Association. Go to http://www.speechtherapy.org.nz/about-nzsta/ethics

I agree to adhere to the NZSTA Code of Ethics if I am accepted into the MSLTPrac programme.

Signed: Date:

The Privacy Act 1993: The University of Auckland undertakes to collect, use and store the information provided by you and two referees for the purposes associated with selection of students into the Master of Speech Language Therapy Practice programme, in accordance with the Privacy Act (1993) and it’s Amendments.

I agree that this information can be used in the manner described.

Signed: Date:

MSLTPrac Clinical Placements: It may be necessary to complete a clinical placement outside of the Auckland region for five weeks each year. The University of Auckland can accept no responsibility for costs incurred as a result of these placements.

I agree to undertake a clinical placement outside of Auckland if required.

Signed: Date: If you are unable to relocate outside of Auckland for these five weeks, please explain below:

Immunisation: Hospitals and other care providers require that people providing clinical services in these settings are immunized against certain diseases. Details are given in our Speech Science Information to Prospective Students (but note that requirements may vary). Failure to provide the immunisation screening results prior to starting the programme will mean that you will be excluded from seeing clients in the clinic and from participating in outside clinical or other placements. The University of Auckland can accept no responsibility for costs incurred as a result of the immunization requirements.

I agree to have any immunisations necessary for me to undertake required clinical practicum placements and to provide a copy of the results of the infectious disease screening procedure to the Clinical Director before I commence the MSLTPrac programme.

Signed: Date: If you are unable to consent to immunisation, please explain below:

Police Record Check: The University of Auckland requires all students to provide a copy of a police record check before commencing this programme. Failure to do this will mean that you will be excluded from seeing clients in the clinic and being sent out on clinical practicum placements. To obtain your copy of a Police Check go to the Ministry of Justice Webpage http://www.justice.govt.nz/services/get-a-copy-of-your-criminal-record/application-forms and download the Priv/F1 form. A Police Check (or equivalent) is required from every country you have lived and worked in for more than 6 months as an adult (over 18 years). For example, if you have lived and studied in NZ for most of your life but spent six months teaching in Japan you would need to provide Police Checks from both NZ and Japan. Make time to allow for this to be processed prior to the start of the academic programme as the Police Check process can take up to 6 weeks.

I agree to have a police record check and will provide a copy to the Clinic Director before I commence this programme.

Signed: Date: If you are unable to consent to a police record check, please explain below: Approval of Previous Qualifications: Admission to the MSLTPrac programme requires the approval of the Faculty of Science to verify that students meet the entry criteria for a Masters programme. Students who have not been enrolled previously at The University of Auckland need to have their previous university qualifications approved by The University of Auckland before an offer of a place in the MSLTPrac programme can be confirmed.

Information on Postgraduate Admission can be found on The University of Auckland’s webpage at http://www.auckland.ac.nz/uoa/home/for/future-postgraduates/fp-study-options/admission-and-enrolment-guide

Online Application: In addition to submitting this application form directly to Speech Science you should complete the University’s online application via the Student Self Service portal at http://www.studentservices.auckland.ac.nz/ by 1st November – this cannot be done retrospectively.

1. Academic Courses: Please attach an official copy of your academic record if you have studied at a University other than The University of Auckland. 1.1 If you are currently a University of Auckland student please indicate below the degree you are currently enrolled in and your Major(s)

1.2 List any undergraduate courses you are currently enrolled in. Provide a brief description of the course if the content is not obvious from the course name, the name of the coordinator, and the University and Department at which you are enrolled. If the course is an Honours dissertation or research thesis, give the title or area, and supervisor.

 Completed an Honours dissertation University Academic discipline Title or Area Supervisor

1.3 For those students who have already completed graduate level research projects, please provide details

1.4 If you speak other languages, please provide us with details:

1.5 Please indicate below if English is not your first language, and if you have recently sat an IELTS test or equivalent. If your degree is from a non-speaking English country, please provide a copy of your IELTS results score with your application, or other evidence of English proficiency. 2. Paid Work Experience Please list in chronological order any paid work experience you have had (note if full-time or part-time). Provide a brief description of job title if not sufficiently informative

Full-time/Part-Time (if Year(s) Work Experience part-time state hours per week)

3. Unpaid Work Experience Please list in chronological order any unpaid work you have done which you think is relevant to speech language therapy.

Full-time/Part-Time (if Year(s) Work Experience part-time state hours per week) 4. Considering your personal attributes (personality, self-image, coping styles, interpersonal characteristics etc) but not considering your current level of acquired knowledge or technical skills, discuss

(a) What is your understanding of the work a Speech Language Therapist does?

(b) As you understand speech language therapy, what are your major strengths? (c) As you understand speech language therapy, what are your major areas for improvement and future development?

(d) What aspects of clinical practice in speech language therapy interest you the most?

DECLARATION

I declare that the information I have given in this application form is true and accurate. If statements I have made are found to be false or inaccurate, I acknowledge that my application may not proceed.

Signed Date