Speech Language Pathology Assistant Interview Form
Student Name:
DOB:
Date:
Student ID Number:
Address:
Phone:
Email:
Which program are you interested in?
SLPA Associate in Applied Science (AAS) 2 year degree
SLPA Diploma program (You must have a BS/BA in Communication Sciences and Disorders or Speech
Language Pathology to check this box.)
How did you find out about the program? (Check all that apply.)
CCC&TI career counselor
Friend
Newspaper article
Radio
College catalog
College web site
Other
The SLPA program is taught via video conferencing. Which campus are you interested in attending?
CCC&TI—Hudson campus
Mitchell Community College—Statesville campus
Central Piedmont Community College—downtown Charlotte campus
Where are you in the process?
CCC&TI application submitted
Transcripts requested from high school and/or colleges attended, if applicable
Placement test taken
Developmental courses taken, if needed.
Information session/interview with SLPA program staff or designee
By signing below, I understand that if I decide to enter the SLPA AAS or Diploma program, CCC&TI will be the degree
awarding college. As such, CCC&TI will be the only college where financial aid can be awarded. I will need to contact the
financial aid department at CCC&TI if I have specific questions.
Student Signature: _________________________________________________________ Date: ___________________