An important part of the Leadership Intern program is service to others. Reaching back after you have been through the program and helping a new member of the program is encouraged. Consider the list of ideas below and mark at least two things you would be willing to do.

Promote the Leadership Intern program by manning a booth a special event

Assist with the Teen Girls Go To College Event

Be paired with a new intern/new student and serve as s “student mentor” during her freshman year

Help organize an community service activity

Speak to community and campus groups about the internship program

Add your own ideas or thoughts on how to reach back

Statement of Commitment

By signing this form, I agree to the following:

I will enroll in at least 6 credit hours per semester.
I will maintain at least a 2.0 cumulative GPA.
I will attend orientation, retreat, by-monthly meetings with my mentor(s), and any other required activities on the attached required activities list.
I will participate in planning and executing a leadership event.
I will provide feedback to the mentors.

I confirm that all information on my application is accurate and I give the Women’s Leadership Center permission to verify any information included in this application. My signature below represents an awareness of my commitment and responsibilities to my mentor(s) and the Leadership Intern program.

* Signature

* Date

Funeral Science AAS Program Application

* First Name

* Middle Name

* Last Name

* Phone

* ASUMH Email

* Address

* City

* State

* Zip

Prerequisites

* Upload transcripts from all previously attended colleges/universities showing final grades and CGPA and/or a copy of course schedule showing enrollment in required class(es) with name of instructor and email address.

Select File(s)

BIOL 1013 Introduction to Human Anatomy and Physiology for Non-Healthcare Majors OR BOTH		Final Grade OR Mid-Term Grade
	BIOL 2004 Human Anatomy and Physiology I & Lab	Final Grade OR Mid-Term Grade
	BIOL 2014 Human Anatomy and Physiology II & Lab	Final Grade OR Mid-Term Grade
CIS 1053 Computer Essentials		Final Grade OR Mid-Term Grade
COMM 1203 Oral Communication		Final Grade OR Mid-Term Grade
ENG 1003 Composition I		Final Grade OR Mid-Term Grade
MATH 1113 Applied Math or higher-level math (provide course name/number in space below)		Final Grade OR Mid-Term Grade
ORT 1001 First Year Experience for Funeral Science		Final Grade OR Mid-Term Grade
Part-time Applicants Only
ENG 1013 Composition II		Final Grade OR Mid-Term Grade
Social Science Elective (provide course name/number in space below)		Final Grade OR Mid-Term Grade

Admissions decisions made based on mid-term grades will be contingent upon final grades.

* Upload three letters of recommendation.

Select File(s)

* Upload documentation of 20 hours of volunteer/job shadowing in the funeral service industry.

Select File(s)

Upload Affiliation Agreement (recommended but not required).

Select File(s)

List any additional certifications or experiences that you feel will benefit you in the funeral service industry.

Important Disclosures about the Program and the Funeral Service Industry

I understand this program is full-time and requires that I follow a specific course rotation of 14-16 credit hours per semester.	* Initials * Date
I understand that all Funeral Science Education curriculum course work must be completed with a grade of “C” or better.	* Initials * Date
I understand that students must maintain a 2.5 GPA and will only be allowed to retake courses from which they withdraw or failed in the first semester upon admission to the program.	* Initials * Date
I understand that students are responsible for any costs associated with the program including field trips and Training Camp.	* Initials * Date
I understand that when I receive my results for each section of the National Board Examination, I must forward a copy of such results to the program coordinator as a condition of graduation.	* Initials * Date
I understand that it is my responsibility to know the licensing requirements for any state in which I intend to practice.	* Initials * Date
I understand that students who have previously been convicted of a crime may be restricted from certain clinical facilities and may be ineligible for some state licenses.	* Initials * Date
I understand that students who have a physical disability should contact the state in which he/she plans to seek licensure to determine if the disability will affect licensure.	* Initials * Date
I understand that a current driver’s license is required prior to enrolling in a clinical or practicum course.	* Initials * Date
I have read and understand the program dismissal policies contained within the Funeral Science Student Handbook.	* Initials * Date

I have read the Funeral Science Student Handbook, specifically the academic expectations, dress and hygiene codes and other student requirements, with which I will comply. I further understand that there may be costs involved for these requirements.

I understand that misrepresenting and/or falsifying any information submitted within this application will result in my immediate termination for consideration within the Funeral Science program.

* Signature

* Date