Speech-Language Pathology Assistant Certificate Program Application

To apply to the program, please complete the online certificate application below, as well as submit the following documents:

Two (2) letters of recommendation

Official transcript(s) that indicate your degree awarded*

Mail official transcript(s) to:
Jenny Rosenquist
SLP-A Program Coordinator
Cal State East Bay
25800 Carlos Bee Blvd, MB 1088
Hayward, CA 94542

GPA calculator for CD coursework (emailed to jenny.rosenquist@csueastbay.edu)

Priority consideration will be given to applicants who identify a speech language pathologist with current ASHA CCC's and CA license to supervise their fieldwork experience.

*Please note: if you completed your degree from Cal State East Bay, you do not need to provide official transcripts.

First Name

Last Name

Middle Initial

NetID

Date of Birth

Former or other full names used:

Street Address

City

State

Zip

Phone Number

E-mail Address

Degree Information

Please list all degree types, including BA/BS, starting with most recent, and provide the relevant GPA.

THE PROVIDED GPA CALCULATOR MUST BE SUBMITTED FOR CD COURSEWORK

Univ. GPA is the GPA for all courses taken at the degree-granting institution
Overall GPA is the GPA for all courses taken at the degree-granting institution AND any college level coursework that was transferred in.

Degree

College/Univ. Attended

Year Rec'd

CD GPA

Univ. GPA

Overall GPA

Degree

College/Univ. Attended

Year Rec'd

CD GPA

Univ. GPA

Overall GPA

Degree

College/Univ. Attended

Year Rec'd

CD GPA

Univ. GPA

Overall GPA

Degree

College/Univ. Attended

Year Rec'd

CD GPA

Univ. GPA

Overall GPA

Degree

College/Univ. Attended

Year Rec'd

CD GPA

Univ. GPA

Overall GPA

Language Proficiency

Please indicate additional spoken language proficiencies below, using “Excellent”, “Good”, “Fair”, or “Poor”

Language

Proficiency

Language

Proficiency

Language

Proficiency

Potential Fieldwork Supervisor

If you are aware of or have an existing supervisor who may be willing to supervise you for your fieldwork placement, please indicate their name, ASHA/CA license number and contact information below.

Personal Statement of Purpose

Résumé of applicable background

Voluntary Self-Identification

Gender

Preferred Gender Pronouns

I certify that the information submitted in this application is true, complete and accurate, and understand that all materials become the property of Cal State East Bay. I understand that any misrepresentation will be cause for denial of admission. I understand that my application potentially may not be reviewed based on GPA. I understand that if my application is incomplete, it will not be reviewed. I also understand that if admitted, I may have to take additional coursework.

Contact Information