Physical Therapist Assistant Program Application

Application for the physical therapist assistant program.

Name

Please include First, Middle, Last and Maiden if applicable

Address

Street or Box number, City, State, Zip

Telephone Number

Email Address

Date of Birth

Gender

Male Female

Age

Social Security Number

List ALL other colleges attended

Please let us know if you have attended any other colleges.

Classes in progress

Please list all classes that are in progress or expecting to take in the summer. NOTE summer classes must be completed by the first week of August.

College Degrees Awarded

Please list any college degrees awarded.

Volunteer or Work Experience

Physical therapy or health related fields only.

Have you ever been treated for substance abuse?

Alcohol, illegal drugs or prescribed medications

Yes No

Have you ever been found guilty or pleaded no contest to any felony or Class A misdemeanor?

Yes No

Signature

I hereby certify, under penalty of perjury, that the foregoing is true and correct to the best of my knowledge.

Date

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