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KC CENTER FOR FAMILY SYSTEMS: POSTGRADUATE E&T SERIES APPLICATION FORM
ACADEMIC YEAR: 2024-2025
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Email
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Your email
Date of Application
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MM
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DD
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YYYY
Name
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Your answer
Home Address
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Your answer
Cell Phone
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Your answer
Employer
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Your answer
Work Address
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Your answer
Work Position
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Your answer
FORMAL EDUCATION (Include undergraduate and graduate degrees, schools, dates of attendance and postgraduate studies)
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Your answer
WORK HISTORY (post bachelor and postgraduate work experience)
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Your answer
PROFESSIONAL LICENSE, CERTIFICATIONS
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Your answer
PROFESSIONAL ORGANIZATIONS & ASSOCIATIONS
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Your answer
FAMILY: Briefly describe your family including important facts and events.
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Your answer
FAMILY OF ORIGIN DIAGRAM: (Use space here, email attachment, or mail to the KC Center)
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Your answer
NUCLEAR FAMILY DIAGRAM: (Use space here, email attachment, or mail to the KC Center)
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Your answer
BOWEN FAMILY SYSTEMS THEORY: Exposure to theory (include formal and informal exposure, undergraduate, postgraduate classes, training, supervision, conferences, workshops, reading, etc.)
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Your answer
Give examples of efforts to think systems and apply theory in family/work setting.
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Your answer
HEALTH: Describe your health including hospitalizations, surgeries, serious accidents, diagnoses, chronic conditions, current medications.
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Your answer
RELATED PERSONAL/PROFESSIONAL ACTIVITIES: Are you currently receiving Supervision, Coaching and/or Participating in Therapy, Seminars, Study Groups, other programs?
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Yes
No
If yes, please explain.
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Your answer
EXPECTATIONS: What are your expectations regarding participation in the Series?
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Your answer
HOW DID YOU LEARN ABOUT THE KC CENTER’S EDUCATION & TRAINING SERIES?
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Your answer
QUESTIONS & COMMENTS
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ADMINISTRATION FEE: An administration fee of $50 may be paid online after you submit; the admin will invoice you via PayPal.
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A copy of your responses will be emailed to the address you provided.
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