Approval Contacts
American Studies Dr. Scott Campbell HRMDr. Albert Cabral Art Therapy Dr. Renee van der Vennet
Art Education Dr. Samantha Nolte Higher Ed Admin Dr. Diane Enerson Music Therapy Dr. Bryan Hunter
Music Education Dr. Mary Carlson Marketing Mr. Mark Weber Speech Pathology Dr. Dawn Vogler-Elias
School of Education Patricia Huntington Physical Therapy Dr. Mary Ellen Vore Social WorkDr. Carol Brownstein-Evans
Phone: (585) 389-2816 Fax: (585) 389-2612 Email:
Last Name__________________________ First Name__________________________ Social Security#_________________________
____________________________________ _____________________________________________________
City State/Zip E-mail Address
_______________________________ __________________________________ _______________________________
Home Phone Cell Phone Work Phone
Education Information
College/University Undergraduate Degree/Major Date Degree Earned GPA
Do you hold licensure or teacher certification? Yes No If yes, list license or certification area/s:
For Federal Reporting Purposes
Date of Birth: ______________ Gender: Male Female Desired Course and Term: ____________________________
(ex. SPF 520, 16/SA)
1. What is your ethnicity? Not Hispanic or Latino Hispanic or Latino
2. What is your race? Mark one or more races to indicate what you consider yourself to be.
White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander
Confirmation of Student Understanding
By signing below, I confirm my understanding that as a non-matriculated student I can take no more than two courses (six credit hours). If I take only one
course in my first term, I must earn a grade of “B” or higher in order to continue with the second approved course. I further understand that approval for non-
matriculated status in no way guarantees my acceptance into a graduate program.
______________________________________ _____________________________________ _______________
Printed Name Signature Date
Requirements for non-matriculation approval (to be completed by approved college designee for program of interest):
Provision Met
Completion of undergraduate degree Yes No
Interview with college designee Yes No
Transcript provided (unofficial acceptable) Yes No
If GPA is under 3.0, explanation provided Yes No N/A
Approval Granted Yes No
If yes, list specific courses approved: TERM(S) Summer 20_____ (specify Sum A or Sum B) Spring 20_____ Fall 20_____
Program in which approval has been granted:
American Studies Education/General Music Education Physical Therapy
Art Education Human Resource Management Music Therapy Social Work
Art Therapy Marketing Higher Ed Stu Affairs Admin Speech Pathology
horization by college designee:
______________________________________ _____________________________________ _______________
Printed Name Signature Date
eted forms need to be submitted to the college designee for approval (see bottom of form for approval contacts)
All sections of this form must be fully complete to be reviewed by the Registrar’s Office located in Smyth Hall, Room 1