Please affix  photograph in this box

 

 

 

UNIVERSITY OF CAPE TOWN
CHILD GUIDANCE CLINIC

 

APPLICATION FOR ADMISSION TO M.A. (CLINICAL PSYCHOLOGY) TRAINING PROGRAMME
Please return to:
The Director,
University of Cape Town Child Guidance Clinic,
Chapel Road, 
Rosebank, Cape,
7700.

Closing date for applications is noon 25 May 2012

TITLE: ............... SURNAME: ........................................  FIRST NAME: ......................................................
DATE OF BIRTH: ................................ Age: ..................................
ADDRESS:..............................................................................................................................................................
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Postal Code: ..................

Telephone/fax No.:  ........................................   Cell No.: ..............................................
Email ..............................................................
(Please report any change of address immediately)

How would you describe yourself, according to the following categories as defined in SA Employment Equity, Act 55 of 1998:

Please tick the appropriate box: Disabled White Black African Black Coloured Black Indian Other

First degree:

Date
completed		 Degree University Majors Level Pass
of Majors
         
         
         

Postgraduate (also give details of uncompleted degrees):

Date completed
or estimated date of completion		 Degree University Areas
(state all areas
covered in Honours)		 Project or
thesis title		 Level
Passed
           
           
           

Additional academic information: Any additional degrees, diplomas, courses completed and distinctions earned: ...........................................................................................................................................................
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      Languages                   Fluent                       Read/Write                      Understand           

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Brief resume of experience and publications:......................................................................................................................................................................................
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Why would you like to become a clinical psychologist?

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If you have any further information which you wish to add, which you feel would have bearing on your application, please write this below:

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Write an informal self-description. In the course of your discussion, mention some of the factors which you believe to be strengths in relation to your effectiveness as a clinical psychologist and some areas which you feel could usefully be strengthened or developed further.

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REFEREES:

Please ask three people (preferably trained in clinical psychology, counselling or personnel psychology) to complete the enclosed Referee Reports, and to return them by the due date.

List the names, addresses and telephone numbers of your referees below:

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Application form Information