Application for Graduation - Adler School of Professional Psychology

GRADUATION PETITION
**EFFECTIVE FALL 2010 TERM**
PLEASE READ INSTRUCTIONS CAREFULLY BEFORE PROCEEDING
The $140 graduation fee must be paid by ALL students. You must complete this form and pay the graduation
fee, regardless of whether you intend to participate in the October commencement ceremony.
This form triggers a series of processes that lead to the awarding of your degree. If this form is not submitted,
your degree will not post and your diploma will not be ordered. Please see the academic calendar for due
dates. Applications received after the deadline are subject to a $50.00 late fee.
The Registrar’s office will perform a comprehensive audit of your academic records once this completed form,
all relevant fees, and all grades are received.
Financial Aid recipients must complete an exit interview and debt management seminar. Both items need to be
completed in order for you to receive your diploma. Please contact Financial Aid at financialaid@adler.edu to
schedule an appointment.
Student accounts must be paid in full at the time of program completion. Any outstanding balance will
prevent the release of diploma(s), transcripts, letters of completion, and prevent the student from participating
in the commencement ceremony, etc. Contact the Student Account Manager’s Office at
studentaccounts@adler.edu for information about your student account or for payment options.
If you apply for graduation and pay the fee but do not qualify to graduate at this time, you must reapply for
graduation. Your graduation fee will rollover, but you must submit a new application and check the appropriate
box in the “Payment Information” section. You must pay a graduation fee for EACH degree earned at Adler
(i.e., if you earn a M.A. degree while working on your Psy.D, you must complete an application and pay the
graduation fee for the M.A. When you complete the Psy.D, you must complete another application and pay a
separate graduation fee – at the then prevailing rate – for the Psy.D). Psy.D students earning their MA
along the way must petition for their MA once their MA requirements are completed.
Certificates completed in the same quarter as a M.A. or Psy.D WILL NOT be billed a separate fee; certificates
completed in a different quarter from a M.A. or Psy.D, or completed on their own, DO require a separate
application and full graduation fee.
Diplomas are ordered at the end of every term. Please allow 8-12 weeks for the printing of your diploma. All
diplomas will be mailed to the address we have on file. If you change your address after submitting this
application, you must notify the Registrar’s Office in writing and indicate if your diploma should be
mailed to your new address.
Psy.D. students may not use the title “doctor” and may not consider themselves finished with their degree
program until their internship is completed, all grades are posted, their final dissertation copies have been
submitted to the PsyD department for binding and the fee paid, and all training paperwork has been received by
the Department of Training & Community Service.
Students who wish to participate in the October commencement ceremony must complete all degree
requirements no later than the last day of the summer semester. Students cannot be enrolled in degree
requirements during the Fall term of the year in which they wish to commence.
By submitting this application, you permit the Adler School of Professional Psychology to print your name in the
commencement program and to release your directory information to the Adler School Alumni Association.
Your attendance at the commencement ceremony does not mean that your degree has been conferred and
that you have graduated from your program.
Please retain this cover page and copy of this application for your records. Your signature indicates
you have read and accept the information listed on this application. All pages of this petition, except
this cover page, must be submitted.

GRADUATION APPLICATION
EFFECTIVE FALL 2010 TERM
STUDENT INFORMATION
Last Name: _______________________________
First Name: ________________________________
Term and year in which ALL degree requirements will be completed:
Spring __________ Summer __________ Fall __________
DEGREE INFORMATION – please specify the degree(s) for which you are applying:
Degrees:
– Clinical Psychology – Counseling Psychology
M.A. – Marriage & Family Counseling
– Counseling Psychology: Art Therapy
– Counseling & Organizational Psychology – Police Psychology
. – Gerontological Counseling
M.A. – Counseling Psychology: Specialization in Forensic Psychology
– Counseling Psychology: Specialization in Rehabilitation Counseling
M.A. – Counseling Psychology: Specialization in Sport and Health Psychology
Certificates:
Advanced Adlerian Psychotherapy
- Group Psychotherapy
Concentrations:
Group Psychotherapy
Abuse Counseling (Specialization)
Doctoral Concentrations:
Traumatic Stress Psychology
-
Child and Adolescent Psychology
Primary Care Psychology
DIPLOMA INFORMATION
Name as you would like it to appear on your diploma (please print):
___________________________________________________________________________________________
Psy.D students: Complete dissertation title (this title will be printed in the commencement program – please print
legibly):
__________________________________________________________________________________________
__________________________________________________________________________________________
Dissertation Chairperson: _____________________________________________________________________

EMPLOYMENT INFORMATION
As you plan to graduate, have you secured employment ___ Yes ___ No
a. Where have you secured employment
b. In your field of study
c. In what way does your new position incorporate Social Responsibility or Community Service
If not, how do you plan to pursue employment What kinds of positions are you interested in finding
Did you gain employment at a practicum or internship placement you secured while at Adler School
Are you interested in applying for loan repayment or loan forgiveness programs ___ Yes ___ No
Are you planning on sitting for licensure ___ Yes ___ No
If yes, which license and in which state
If not, what are your professional/career goals
COMMENCEMENT INFORMATION
Only students who attend the commencement ceremony will receive their regalia and gift.
Do you plan to attend the commencement ceremo
(if no, proceed to “Payment Information”)
How many guests will be in your party _____________________
Will YOU require any accommodations (e.g., stage ramp for wheelchair, ASL interpreter, etc.)
_________________________________________________________________________________
Height: _______ Weight: _______ lbs Cap/Hat size: __________
PAYMENT INFORMATION
GRADUATION FEE (PER DEGREE): $140 – REQUIRED OF ALL STUDENTS (ADD $50.00 LATE FEE IF
SUBMITTING AFTER DEADLINE)
please use the attached credit card authorization form)
Student’s Signature: _________________________________
Date Submitted: ________________
Your signature indicates you have read and accept the information listed on this application.
Office Use Only:
Date received ___________ Payment included No account balance
Audit completed
Approved for graduation - staff initials & date___________

ADLER SCHOOL OF PROFESSIONAL PSYCHOLOGY
17 N. Dearborn
Chicago, IL 60602
Non-Tuition
Credit Card Payment Authorization
Date: __________________________
ID #: _______________________________
Name: _______________________________________________________________
Day Phone #:_____________________
Evening Phone #:____________________
I hereby provide/authorize payment in the amount of:
(If amount is left blank, form will not be processed)
$____________ . _____
Master Card Amex Discover
V I S A I S N O T A C C E P T E D
Card # ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Security Code ___ ___ ___ ___ Exp. Date: _______ / _______
(month) (year)
Card Billing Street Address and Zip ______________________________________
(Example: 12345 Any Street, 60601 – This is the address associated with the card, not the student)
Signature: ____________________________________________________________
Cardholder name: ______________________________________________________
(Please print name exactly as it appears on card)
*Please ensure that this form is completed in full. Missing/incorrect information may result in processing
delays. Payment is considered “received” only once a fully completed form has been processed. This
payment form is NOT FOR TUITION PAYMENTS. Tuition payments received by this form will not be
accepted and student accounts will be considered late.
Please check one:
PsyD Deposit Start Term: _______________ Transfer Credit Fee
MA Deposit Start Term: _______________ Application Fee
Other: _______________________________ Transcript Fee
Received by (staff/work study name):_______________
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