The University of Texas at San Antonio - Department of Kinesiology, Health and Nutrition
Coordinated Program in Dietetics
Program Application
The completed typed Program Application should be sent directly to the Coordinated Program in
Dietetics (CPD), along with your two reference forms and a personal statement addressing
interests, motivation and professional goals.
Return Program Application To:
Coordinated Program in Dietetics
Department of Kinesiology, Health and Nutrition
One UTSA Circle
San Antonio, Texas 78249
Only completed applications submitted with all supporting documents that are received by the
May 1st deadline will be considered for admission. Applicants who are taking coursework during
the spring or summer semester of the application process, must submit a list of coursework in
process.
Application Checklist for User:
Completed Application Form
List of Courses in Progress (Spring or Summer Sessions)
Personal Statement of Interest
Two Reference Forms (from a faculty or advisor preferred) with Applicant’s signed waiver.
The forms must be included along with the application, in a sealed and signed envelope.
IMPORTANT NOTE:
To be considered for the CPD, students must be admitted into UTSA as an undergraduate student.
Admission to UTSA is processed through the Online “Apply Texas” application system. Under major,
applicant should select Health or undecided.
I am currently a UTSA student
Applied on
(date)
Refer to the UTSA catalog for a complete description of the admission requirements to the Coordinated
Program in Dietetics (CPD).
UTSA CPD Application, Revised 1/9/2014
Page 1
The University of Texas at San Antonio - Department of Kinesiology, Health and Nutrition
Coordinated Program in Dietetics
Program Application
Only completed applications, received by the May 1st deadline date, will be considered for admission decisions.
I. Personal Information
Application for
Academic Year
Fall
Admitted to UTSA?
Yes
No
Mailing Address Street
Prefix
Full Legal Name (Last) (First) (Middle
Ms.
Mr.
Mrs.
Contact Phone Number (with area
Back-up Phone Number (with area code)
code)
City, State, Zip and County
Primary email address
Other email address
Ethnicity (Optional)
Previous name(s)
RESIDENCE CLASSIFICATION INFORMATION
US Citizen?
Yes List city, state, county where born
No - give country of citizenship
Type of Visa/Expiration Date
Resident Alien ID Number (if applicable) Attach copy
Texas Resident Yes
If yes, complete:
County of residence
Months
No
If less than 12 months, prior residence:
Street City, State
II. Honors, Awards, Life Experiences
A.
Extracurricular Activities, Honors and/or Awards: Include name and dates of volunteer activities, participation in
organizations, elected offices held, scholarships, awards, recognitions, and special certifications.
UTSA CPD Application, Revised 1/9/2014
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The University of Texas at San Antonio - Department of Kinesiology, Health and Nutrition
Coordinated Program in Dietetics
B. Employment Experience
If you have been employed in the last 12 months, provide the information requested below.
Position:
Employer
City/State
Dates
Position:
Employer
City/State
Dates
C. Within the last 12 months, have you been a student at an institution of higher education? Yes
Institutions:
Part-time
Full-time
Scholastic Achievement (as of May
No
)
If applicable, highest degree attained:
Major:
Institution where degree was earned:
Year:
DPD Verification Statement from:
Year:
D. Language skills other than English
(Mark one)
Beginning
Intermediate
Proficient
(Mark one)
Beginning
Intermediate
Proficient
Language
Language
III. List of Courses in Progress or Pending Pre-requisites
Course Id
Course name
UTSA CPD Application, Revised 1/9/2014
Institution
Expected Completion Date
Page 3
The University of Texas at San Antonio - Department of Kinesiology, Health and Nutrition
Coordinated Program in Dietetics
IV. Personal Statement
Please include a statement letter (double spaced, 12-font, 1-inch margins – no more than one page in
length) addressing the following: interests, motivation, career goals, commitment and knowledge of
the profession.
V. Signature (Unsigned applications will NOT be considered)
The committee will not evaluate your application for this program until you are admitted to UTSA, and this
application form, personal statement and two reference forms are submitted.
By signing this application you are certifying that you have read and understand the admission
requirements for the CPD.
Further: I understand that the Admissions Committee cannot make any decision regarding my application
until the ”Apply Texas” application, transcripts for all courses taken, supporting documents, and this
supplemental application have been received. If I have courses in progress during the application
process, I understand that if I am accepted into the program, that acceptance is conditional upon
satisfactory completion of these courses. Transcripts showing additional work after acceptance must also
be submitted.
I further understand that all actions on admission of students to the Coordinated Program in Dietetics are
the prerogative of the Admissions Committee. I understand that the information submitted herein will be
relied upon by officials of The University of Texas at San Antonio to determine my status for admission
and residency eligibility. I certify that the information in this application is complete and correct and
understand that the submission of false information is grounds for rejection of my application, withdrawal
of any offer of acceptance, cancellation of enrollment, or appropriate disciplinary action including
dismissal from the program.
I hereby certify that any statements submitted in conjunction with this application are my own
work.
Signature (required) ________________________________________________________________
Date _
Note: Criminal Record Check
A criminal background check is a requirement during the semesters in which a student enrolls in field-based
practicums. Students will be required to submit to a Criminal Record Check for practicums associated with schools,
health care facilities, hospitals and clinics. It is the responsibility of the student to determine if his or her criminal
history background will present a problem before applying for admission to the program. Students with
problematic criminal history will not be able to complete most of the field-experiences that are required by the
program.
UTSA CPD Application, Revised 1/9/2014
Page 4
The University of Texas at San Antonio - Department of Kinesiology, Health and Nutrition
Coordinated Program in Dietetics
Waiver and Request for Reference Form
Please read carefully
INSTRUCTIONS: Applicants must complete this first page. Print this cover page along with the following
two pages, and give the three pages to the person completing the reference form. Ask the person
writing the reference to complete the form and return to you signed and dated. Request a signature on
the sealed envelope. Submit only two completed reference forms with the application packet.
APPLICANT’S SECTION
Applicant’s Name:
Expected Date for Program Admission:
If the person completing the reference has taught you, indicate course information
Course number/Title:
Semester/Year:
Credit hours:
Grade:
The applicant should sign and date one of the following statements: Family Educational Rights and
Privacy Act of 1974 (FERPA).
Under the provisions of this Act, you have the right to see recommendations for admission. Please
choose the appropriate phrase below and sign your name.
I
Waive
Do Not Waive any right of access that I may have to this recommendation form.
Applicant’s signature ___________________________________________________
Date
UTSA CPD Application, Revised 1/9/2014
Page 5
The University of Texas at San Antonio - Department of Kinesiology, Health and Nutrition
Coordinated Program in Dietetics
REFERENCE’S SECTION
Reference’s Name:
_________________________________________________________________
Title: ________________________________________________________________________________
Institution or Organization: _____________________________________________________________
Reference’s Address: ___________________________________________________________________
Phone: ___________________________
e-Mail: _________________________________
For how long have you known this applicant?
In what capacity have you known this applicant? Advisor:
Other:
Teacher:
Work Supervisor:
Specify________________________________
How well do you know this applicant? _____________________________________________________
For the qualities, traits or behaviors listed on the grid below, please rate the student in areas that you feel you can judge. The
grid is provided to assist you in evaluating the applicant in comparison with other students or co-workers of the same level.
Check the most appropriate box for each category, and include a short narrative in the space that follows along with your
signature.
Qualities, Traits, Behaviors
Unsatisfactory --------------------------------------------- Outstanding
Commitment to Learning - has the ability to self-assess,
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
the interrelationship of ideas or elements in relation to the
totality and to question logically arguments and to recognize
and differentiate facts, illusions, assumptions, and to discern
relevant from irrelevant.
Communication Skills: Oral - expresses thoughts clearly
and is able to interact and relate with colleagues and
instructors.
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Written – able to write thoughts and reports in a concise and
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
self-correct, and self-direct to identify needs and sources of
learning; and to continually seek new knowledge and
understanding.
Analytical Skills/Problem Solving - able to evaluate
options, assess problems/issues and determine best solutions,
able to implement solutions and evaluate outcomes.
Conceptual Skills/Critical Thinking - able to understand
logical manner, using correct spelling, grammar, punctuation,
even writing style and actual wording.
Interpersonal Skills – able to interact effectively with others
and to deal effectively with diversity issues, demonstrates
respect for others such as colleagues, supervisors instructors,
and peers; able to work as a team member.
Professionalism - shows work ethics, and appropriate
behavior and personal appearance.
Leadership Potential - assumes responsibility
independently, is goal oriented, able to set priorities, shows
concerns for others, is a self-initiator, and self-sufficient, able
to influence others by bringing positive changes.
UTSA CPD Application, Revised 1/9/2014
Page 6
Unable to
Evaluate
The University of Texas at San Antonio - Department of Kinesiology, Health and Nutrition
Coordinated Program in Dietetics
Initiative/Motivation – initiates tasks, work on assignments
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
without reminders or with minimum prodding.
Punctuality - able to complete tasks, assignments or work in
a timely manner, shows to class, work and/or appointments on
time.
Adaptability - able to easily adjust to new situations and
environment.
Reaction to Stress - responds to corrective criticism in a
positive manner; remains calm under difficult situations and
without complaints.
Perseverance - shows patience and commitment to
complete work, tasks or assignments.
Creativity - able to generate new ideas, solutions and
activities when presented with a task.
Organizational Skills - able to set priorities, to complete
tasks and to use resources efficiently and effectively, on timely
and organized manner.
Works Independently - assumes responsibility for tasks
without constant supervision or reminders.
Responsibility/Maturity/Integrity – able to fulfill
commitment and to be accountable for actions and outcomes,
readily admits mistakes and takes corrective action.
Overall Potential in Dietetic Careers
Do You:
(Check appropriate box)
Not Recommend
1
Recommend
2
3
Highly Recommend
4
5
Additional Information: Use to add to characteristics rated above. Indicate applicant's strengths and those qualities that
require further development.
Strengths:
Qualities that require further development:
Signature ___________________________________________________ Date ________________________
Adapted from various sources: The American Dietetic Association and Dietetic Educators of Practitioners Practice Group (6/2008) and PT Journal Education 9:1, Sp 1995.
UTSA CPD Application, Revised 1/9/2014
Page 7
The University of Texas at San Antonio - Department of Kinesiology, Health and Nutrition
Coordinated Program in Dietetics
Waiver and Request for Reference Form
Please read carefully
INSTRUCTIONS: Applicants must complete this first page. Print this cover page along with the following
two pages, and give the three pages to the person completing the reference form. Ask the person
writing the reference to complete the form and return to you signed and dated. Request a signature on
the sealed envelope. Submit only two completed reference forms with the application packet.
APPLICANT’S SECTION
Applicant’s Name:
Expected Date for Program Admission:
If the person completing the reference has taught you, indicate course information
Course number/Title:
Semester/Year:
Credit hours:
Grade:
The applicant should sign and date one of the following statements: Family Educational Rights and
Privacy Act of 1974 (FERPA).
Under the provisions of this Act, you have the right to see recommendations for admission. Please
choose the appropriate phrase below and sign your name.
I
Waive
Do Not Waive any right of access that I may have to this recommendation form.
Applicant’s signature ___________________________________________________
Date
UTSA CPD Application, Revised 1/9/2014
Page 8
The University of Texas at San Antonio - Department of Kinesiology, Health and Nutrition
Coordinated Program in Dietetics
REFERENCE’S SECTION
Reference’s Name:
_________________________________________________________________
Title: ________________________________________________________________________________
Institution or Organization: _____________________________________________________________
Reference’s Address: ___________________________________________________________________
Phone: ___________________________
e-Mail: _________________________________
For how long have you known this applicant?
In what capacity have you known this applicant? Advisor:
Other:
Teacher:
Work Supervisor:
Specify________________________________
How well do you know this applicant? _____________________________________________________
For the qualities, traits or behaviors listed on the grid below, please rate the student in areas that you feel you can judge. The
grid is provided to assist you in evaluating the applicant in comparison with other students or co-workers of the same level.
Check the most appropriate box for each category, and include a short narrative in the space that follows along with your
signature.
Qualities, Traits, Behaviors
Unsatisfactory --------------------------------------------- Outstanding
Commitment to Learning - has the ability to self-assess,
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
the interrelationship of ideas or elements in relation to the
totality and to question logically arguments and to recognize
and differentiate facts, illusions, assumptions, and to discern
relevant from irrelevant.
Communication Skills: Oral - expresses thoughts clearly
and is able to interact and relate with colleagues and
instructors.
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Written – able to write thoughts and reports in a concise and
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
self-correct, and self-direct to identify needs and sources of
learning; and to continually seek new knowledge and
understanding.
Analytical Skills/Problem Solving - able to evaluate
options, assess problems/issues and determine best solutions,
able to implement solutions and evaluate outcomes.
Conceptual Skills/Critical Thinking - able to understand
logical manner, using correct spelling, grammar, punctuation,
even writing style and actual wording.
Interpersonal Skills – able to interact effectively with others
and to deal effectively with diversity issues, demonstrates
respect for others such as colleagues, supervisors instructors,
and peers; able to work as a team member.
Professionalism - shows work ethics, and appropriate
behavior and personal appearance.
Leadership Potential - assumes responsibility
independently, is goal oriented, able to set priorities, shows
concerns for others, is a self-initiator, and self-sufficient, able
to influence others by bringing positive changes.
UTSA CPD Application, Revised 1/9/2014
Page 9
Unable to
Evaluate
The University of Texas at San Antonio - Department of Kinesiology, Health and Nutrition
Coordinated Program in Dietetics
Initiative/Motivation – initiates tasks, work on assignments
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
without reminders or with minimum prodding.
Punctuality - able to complete tasks, assignments or work in
a timely manner, shows to class, work and/or appointments on
time.
Adaptability - able to easily adjust to new situations and
environment.
Reaction to Stress - responds to corrective criticism in a
positive manner; remains calm under difficult situations and
without complaints.
Perseverance - shows patience and commitment to
complete work, tasks or assignments.
Creativity - able to generate new ideas, solutions and
activities when presented with a task.
Organizational Skills - able to set priorities, to complete
tasks and to use resources efficiently and effectively, on timely
and organized manner.
Works Independently - assumes responsibility for tasks
without constant supervision or reminders.
Responsibility/Maturity/Integrity – able to fulfill
commitment and to be accountable for actions and outcomes,
readily admits mistakes and takes corrective action.
Overall Potential in Dietetic Careers
Do You:
(Check appropriate box)
Not Recommend
1
Recommend
2
3
Highly Recommend
4
5
Additional Information: Use to add to characteristics rated above. Indicate applicant's strengths and those qualities that
require further development.
Strengths:
Qualities that require further development:
Signature ___________________________________________________ Date ________________________
Adapted from various sources: The American Dietetic Association and Dietetic Educators of Practitioners Practice Group (6/2008) and PT Journal Education 9:1, Sp 1995.
UTSA CPD Application, Revised 1/9/2014
Page 10