Supplementary Application Form Speech Science

List the courses you would like to enroll in to complete the 120 points required for a PGDSC

Please note there are limited places available for any Psychology courses at 700 level and entry is GPA ranked. Students intending to enrol in courses outside the School of Psychology should contact that School/Department/Faculty directly.

References

Please forward two letters of recommendation to speech.science@auckland.ac.nz. Referees should comment on your academic aptitude, research skills, and potential for success in this programme. If one referee cannot comment on your skills and experience in a particular area, ensure your other referee can comment on this topic. References are not accepted from family members or friends. Please ensure your referees sign their reference or they will not be accepted. The closing date for references is November 1.

I agree that members of the Selection Committee may speak to my referees and other academic staff for the further information relevant to the selection into the programme.

Yes

List the name, address, phone and email contact information for each of your referees.

Declarations

NZSTA Principles and rules of ethics

I agree to maintain the confidentiality of case examples or participants in any Speech Science learning activity. I will not disclose the names or any identifying details of people who are participating in Speech Science academic, research or clinical course activities nor will I discuss this information with anybody other than classmates and staff in the Speech Science programmes.

I agree

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 Speech Science programmes, in accordance with the Privacy Act (1993) and its Amendments.

I agree

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

PHOTOGRAPHIC IMAGES & AUDIO/VISUAL FOOTAGE: The University of Auckland is committed to quality education and training. Toward this end, digital/film photographs and/or video will be taken of the students as part of School of Psychology teaching and learning and can be used to provide feedback to students to improve their performance, formally assess student achievement and/or competency, help evaluate and improve the programme, teaching and assessment processes, aid in the teaching of future students (institutional purpose), and research (scholarly purposes).

I agree

I agree to have audio/visual footage and photographs taken of me during classroom and clinical activities for the purposes described.

IMMUNISATION (if you are enrolled in any of the following course(s): SPCHSCI 711, 713, and research courses (Special Topic and Research Project) involving client-contact): Hospitals and other care providers require that people providing clinical services in these settings are immunised against certain diseases. Failure to provide the immunisation screening results prior to starting the programme will mean that you will be excluded from seeing clients. The University of Auckland can accept no responsibility for costs incurred as a result of the immunisation requirements. More information

I agree

I agree to have any immunisations necessary for me to undertake required courses and to provide a copy of the results of the infectious disease screening procedure to the Clinical Director before I commence the PGDSC (Speech Science) programme.

If you are unable to consent to immunisation, please explain why:

CRIMINAL CONVICTION HISTORY REPORT (if you are enrolled in any of the following course(s): SPCHSCI 711, 713, and research courses (Special Topic and Research Project) involving client-contact): The University of Auckland requires all students enrolled in the courses that involve working with vulnerable populations such as people in hospital or children to provide a copy of a Criminal Conviction History Report (or equivalent) and sign Vetting Service Request and Consent form before commencing the programme. Failure to do this will mean that you will be excluded from seeing clients in the clinic and/or being sent out on clinical practicum placements. A Criminal Conviction History Report (or equivalent) is required from every country (other than New Zealand) 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 Criminal Conviction History from both NZ and Japan. Make time to allow for this to be completed prior to the start of the academic programme as the process of obtaining Criminal Conviction History Report (or equivalent) can take several weeks. The Report has to be no more than 6 months old at the time when the programme commences (mid-February). Please note that the University of Auckland can accept no responsibility for costs incurred as a result of obtaining the Criminal Conviction History Report or equivalent.

I agree

I agree to provide a Criminal Conviction History Report(s) or equivalent(s), and Vetting Service Request & Consent Form to the Clinical Director before I commence this programme.

If you are unable to consent to a Criminal Conviction History Report, please explain below:

Please do not enter any credit card information into this form.