Palmetto Health Baptist

PALMETTO HEALTH BAPTIST TAYLOR AT MARION STREET COLUMBIA, SOUTH CAROLINA 29220

APPLICATION FOR MUSIC THERAPY CLINICAL TRAINING PROGRAM

NAME ______(last) (first) (middle)

CURRENT ADDRESS ______(street) (apt. no)

______(city) (state) (zip)

PERMANENT ADDRESS ______(street) (apt. no.)

______(city) (state) (zip) E-MAIL ADDRESS ______

CURRENT PHONE ( )______PERMANENT PHONE ( _)______

DATE OF BIRTH __/___/___ SOCIAL SECURITY NO. ____-_____-_____

MUSIC THERAPY ADVISOR ______(full name)

______(address) (city) (state) (zip)

AREAS OF INTEREST ___ Geriatric ____Adolescent ____Adult

___Children ____Other- ______(specify)

PROFICIENCY ON WHAT INSTRUMENTS? ______

MAJOR INSTRUMENT ______MINOR INSTRUMENT ______

TYPE OF DEGREE ______

WILL DEGREE BE GRANTED BEFORE OR AFTER INTERNSHIP? ______

(over) FOR NEXT QUESTIONS , WHERE APPROPRIATE, PLEASE SPECIFY FULL INFORMATION, INCLUDING NAME AND TYPE OF FACILITY, NAME OF SUPERVISOR, AND DATES. USE ADDITIONAL PAGES IF NECESSARY.

DESCRIBE ALL PRE-CLINICAL EXPERIENCES:

WHY DID YOU CHOOSE PALMETTO HEALTH BAPTIST?

WHAT DO YOU HOPE TO GAIN FROM YOUR INTERNSHIP?

WHAT OTHER CLINICAL TRAINING FACTILITIES HAVE YOU APPLIED TO?

DATE YOU CAN BEGIN YOUR INTERNSHIP: ____/____/____

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY ABILITY.

______(date) (signature)

BEFORE YOUR APPLICATION CAN BE CONSIDERED COMPLETE, YOU MUST:

1. Submit a certified transcript from any college or university you are presently attending or have attended (must have original seal of registrar).

2. Submit two (2) letters of recommendation, one (1) of which must be from your music therapy advisor. Both letters must include an assessment of your interpersonal skills, music skills, and knowledge of music therapy practice and procedure.

3. Interview in person or by telephone with the Clinical Training Director.

4. Demonstrate functional musical skills through two (2) songs each on guitar and piano accompanied by voice. This may be accomplished through audition with the Clinical Training director or by audiotape.

APPLICATION AND INFORMATION MUST BE MAILED TO THE FOLLOWING ADDRESS:

BETSY C. NEAL, MT-BC MANAGER OF ADJUNCTIVE THERAPY PALMETTO HEALTH BAPTIST TAYLOR AT MARION STREET COLUMBIA, SOUTH CAROLINA 29220 (803) 296-5546