4000 Lancaster DR NE
PO Box 14007 ● Salem, OR 97309-7070
Human Services
Program Application Packet
Winter Term 2016
Application Deadline for Winter Term 2016 extended to– November 6, 2015
Packet Includes:
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Program Outline
Human Services Program Application Information
Human Services Application Form
It is the policy of Chemeketa Community College and its Board that there will be no discrimination or
harassment on the basis of race, religion, color, sex, age, national origin, ethnic origin, sexual
orientation, gender identity, marital status, citizenship status, pregnancy and related conditions, family
relationship, veteran’s status, disabilities and tobacco usage in any educational programs, activities or
employment. Persons having questions about equal opportunity/affirmative action should contact the
Affirmative Action officer at 4000 Lancaster Dr. NE, Salem, Oregon 97309-7070, or call 503-399-4784. To
request this publication in an alternative format, please call 503.399.5192.
HUMAN SERVICES PROGRAM OUTLINE
The Human Services Program (HSP) provides an environment which broadens
perspectives, builds self-awareness, and develops professional skills for effective
human services work.
The HSP curriculum is designed to prepare students for entry-level staff positions in
human services agencies.
Degrees/Certificates Students entering the program choose to earn one of two
degrees or a certificate 
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Associate of Applied Science Addiction Studies
Post-baccalaureate Addiction Counselor Certification
Associate of Applied Science Social Services
Traditional Health Workers Certification (attached application form not required)
The Human Services program is recognized by the National Association of Alcohol and
Drug Abuse Counselors as an educational provider. Most courses offered by the
program can be used for continuing education requirements for many certified and
licensed professionals.
The program combines academic work with 25 credits of practicum, integrating
academic and practical experience. Students with criminal histories, especially personto-person convictions, may be prevented from obtaining the necessary field experience
required for program completion.
Criminal Background Check/Drug Testing Although this program does not require
background checks or drug testing, student practicum sites may require it. Whether
you are accepted to a practicum site, or are hired or promoted for a future job may
depend on the information revealed in a background check. For some jobs, screening is
required by federal or state law. The current emphasis on security and safety has
dramatically increased the number of employment background checks conducted. For
more information, visit privacyrights.org.
Advising and Coursework The HSP core curriculum is designed to be taken in
sequence with many courses requiring prerequisites. To plan coursework successfully,
you will be assigned an academic advisor within the program who will work with you
throughout your time with us. While faculty will work closely with students to determine
an appropriate class schedule, acceptance into the Human Services program does not
guarantee enrollment in to all program classes during a specific term. You will select the
classes you take each term based on your schedule, finances, other obligations and
class availability. You can successfully earn your certificate or degree whether you
attend part-time or full-time.
More information at http://www.chemeketa.edu/programs/humanservices/
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Human Services Program Application Information
Application Deadline for Winter Term 2016 – November 6, 2015
Admission Criteria
To be admitted to the Human Services Program, you must be enrolled at Chemeketa
Community College www.chemeketa.edu/earncertdegree/ and meet all of the following
criteria:
1. You must have passed Reading 90 or placed higher on college entrance
placement exams, as indicated by your placement test scores or your unofficial
college transcript from an accredited institution.
2. Prior to starting the Human Services Program you must have completed HS152
and WR121 with a grade of C or better, as indicated on your unofficial college
transcript from an accredited institution.
3. You must write and submit a 350-400 word essay.
4. You must complete and submit the Program Application Form, along with a $25
nonrefundable program application fee by the deadlines indicated at the top of
this page.
5. Applicants will participate in small group interviews and a computer writing test at
the Salem Chemeketa campus on November 20. They will be notified of their
appointment time via their MyChemeketa e-mail.
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Instructions to Complete Application
1. Print a copy of your Chemeketa Community College placement exam scores from My
Chemeketa to attach to the application. Students placing into Reading 90 or below must
pass Reading 90 prior to submitting this application.
2. Obtain your unofficial college transcript(s) from an accredited institution, including
Chemeketa Community College, to attach to the application. Your transcript must
indicate completion of HS152 and WR121 with a grade of C or better, as well as
Reading 90, if applicable. Students currently enrolled or planning to enroll in one or
both of these courses prior to admission must indicate this on their application.
3. For the Addiction Counselor Certification Preparation Post-Baccalaureate (ACCP),
provide a copy of your unofficial college transcript listing your degree: Bachelor of Arts
or Science, Master of Arts or Science, or doctoral degree.
4. Write a typewritten, double-spaced 350 to 400 word essay. For Addiction Studies or
ACCP applicants the topic is: “Why I want to be an addiction counselor.” For Social
Services applicants the topic is: “Why I want to be a social services worker.”
5. Complete both sides of the attached Human Services Application Form and sign it.
Include with it the required non-refundable program application fee of $25.
7. Attach your placement exam scores, unofficial college transcripts and your essay to
the application form and submit it to the Enrollment Center. Applications must be
submitted in person between the hours of 8 a.m. - 5:00 p.m. in the Enrollment
Center in Building 2 Room 200 on Chemeketa's Salem campus. The nonrefundable $25 application fee must accompany the application. Incomplete
applications will not be accepted.
8. Students will participate in group interviews and a writing assessment due to the
limited availability of practicum sites. Group interviews will be held November 20, 2015
on the Salem campus. Applicants will be notified by November 16, 2015 via their
My.Chemeketa e-mail of the time and location of these events.
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Chemeketa Community College
Human Services Program Application Form
Winter Term 2016
Application Deadline for Winter Term 2016 – November 6, 2015
Complete front and back page. Submit this application form, along with the other required materials to
Admissions in Enrollment Center in Building 2, Room 201 on the Salem Campus by the above date.
For questions about the application process, email Program Chair Yolanda.martinez@chemeketa.edu
Name (print)__________________________________________________________________
Student ID/K#________________________________
Address(print)__________________________________________________________________
Street #
City
State
Zip code
Home Phone_______________________Other Phone_________________________________
Chemeketa e-mail_______________
_@my.chemeketa.edu
Degree or certificate you are applying for (select one only):
____Addiction Studies AAS
HM03
____Addiction Counselor Certificate Preparation Post- Baccalaureate HM04
____Social Services AAS HM11
If you have not yet taken HS152 Stress Management or WR121, do you plan to enroll in
them Fall term, 2015? YES_____
NO______
Checklist and Signature Page Required
I have attached the following documents to this application form:
 Chemeketa placement exam scores
 Unofficial transcripts for all college coursework
 Essay
 $25 application fee (may be paid by check, money order, debit/credit card or cash)
 I have read the Human Services Program application information and will retain it for my
reference.
 I understand that admission to the Human Services Program for Fall Term 2015 or
Winter Term 2016 is dependent on my having successfully completed all prerequisite
courses with a C or better.
 I understand that Addiction Studies and ACCP students in recovery from a substance use
disorder may start practicum only after two consecutive years of sobriety while living
under independent living conditions or recovery housing for the immediate past two years
(OAR 309-032-1520).
 I understand that if I qualify for admission, I will be placed on the Human Services
Program admission or alternate list based on the program review of my application
packet. For Addiction Studies and ACCP applicants, admission will also be based on the
group interview and writing assessment.
 I understand that applicants who need accommodations for the writing assessment must
arrange these through the Student Disability Office, 503-399-5192, 2/174 one week prior
to the testing date.
 I understand that I will be notified by My.Chemeketa e-mail of my status in the program,
i.e. interview dates, acceptance, alternate, or not admitted.
 I understand that I must notify Enrollment Services (503-399-5001) and the Faculty
Secretary (503-399-5048) of any address, phone and e-mail changes.
 I am submitting this application for admission into the following program:
 Associate of Applied Science Addiction Studies
 Addiction Counselor Certification Preparation Post-Baccalaureate
 Associate of Applied Science Social Services
 I hereby attest that all of the documentation I have submitted with this packet is accurate
and authentic.
Applicant Signature______________________________________________Date____________
Print Name_____________________________________________________