APPLICATION AND SCREENING FORM

PSYCHOLOGY 491 - PROFESSIONAL FIELD EXPERIENCE
West Virginia University - Department of Psychology

INSTRUCTIONS:

Complete the attached APPLICATION AND SCREENING FORM to apply for the Psychology 491 program by the due date.

RECOMMENDATION FORMS by faculty or graduate students in the Psychology Department are now OPTIONAL. If choosing to submit recommendation forms, you should give the appropriate link to faculty or graduate students who know you well enough to rate your suitability for the Psychology 491 program. They will return the forms directly to Dr. McWilliams.

Questions about the program and the application process should be directed to
Dr. Stephanie McWilliams (e-mail: srmcwilliams@mail.wvu.edu, phone: 304-293-0834, office: Room 1234).

Name Name * First Last
Student Number (WVU ID #) *
WVU Mix Email *
Phone Phone * - ### - ### ####
Major
Psychology Adviser

Psychology Adviser Dr. Elizabeth Levelle Dr. Sharon Tenenholz Dr. Elisa Krakow Dr. Brennan Armshaw Other Other
Current Year in School
Anticipated date of graduation
Overall GPA
Number of credits desired for PSYC 491 enrollment *
Semester of placement requested *
Year of placement requested (*please make sure this reflects the year you plan to enroll, which is not necessarily the current year....if the year is incorrect your application will not be considered)
Must be 4 digits. Currently Entered: 0 digits.
List in rank order up to six placement sites where you would like to interview. See the program description for information on available sites. You also may list sites or locations that are not included in the program description if you are interested in arranging your own placement. Be sure to submit a Request for Placement Approval before finalizing a placement if it is not listed on the list of available sites.
Choice 1
Choice 2
Choice 3
Choice 4
Choice 5
Choice 6
Have you

Have you participated in 491 before? been approved of 491 before? if you have participated or been approved, indicate semester, year, and placement below:
Do you have access to transportation to the sites you have chosen?
If you previously participated in or were approved for the course, you do not need to complete remainder of the form or obtain additional recommendations.
What are your areas of interest in psychology?
What are your plans after finishing your Bachelor’s degree?
List any paid jobs you have held
List any volunteer work you have done
List by number the Psychology courses you have completed and those you are currently taking (for spring placements, also list courses planned for summer and fall):
Completed
Taking
Planned
List any activities you have engaged in with individual faculty members or graduate students in the Psychology Department (including PSYC 490, 495, and 498):
Below or on an attached sheet, briefly describe why you would like to participate in Psychology 491.
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APPLICATION AND SCREENING FORM

APPLICATION AND SCREENING FORM

If you previously participated in or were approved for the course, you do not need to complete remainder of the form or obtain additional recommendations.

List by number the Psychology courses you have completed and those you are currently taking (for spring placements, also list courses planned for summer and fall):