Contact Us

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Contact Information

First Name:

Last Name:

Address:

City:

State:

Phone:

Email:

Are you currently employed?

Employment status?

YesNo

Where are you employed?

How did you hear about the ACEP program?

Method?

If other, please explain

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Education

Please list the school's name, location, and years attended (or year graduated) for the following:

High School/GED, other training, certificates, military, trade school, etc.

Associate's or bachelor's degree or # credits towards degree / Major(s)

Advanced Degrees or graduate credits / Major(s)

Professional Licenses

Do you have experience in Human Services?

YesNo

Describe your experience:

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Financial Information

Note: The UMass Boston ACEP Program is not eligible for FAFSA-based financial aid.

How would you prefer to pay for the program? Check all that apply

Self-PayInterested in UMASS payment planLoanDo you have a third-party payor such as MASS REHAB, VA, employer, etc.?

Professional References

Reference #1

First Name

Last Name

Relationship

Phone Number

Email:

Reference #2

First Name

Last Name

Relationship

Phone Number

Email:

Interest

Please explain your interest in the ACEP Program and your goals upon completing the program:

Acknowledgement

By clicking the checkbox, I understand my information will be shared with university staff to complete my request.

Acknowledgement

ACEP Program Application Form

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