Associate of Applied Science Degree Physical Therapist Assistant Application Fall 2018

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Associate of Applied Science Degree Physical Therapist Assistant Application Fall 2018"

Transcription

1 Moving Mountains Building Communities Physical Therapist Assistant Application Fall 2018 Open date: July 2017 Applicants can begin submitting program applications. Close date: Friday, March 30, 2018, 5PM All required documentation listed on the application checklist must be received by the Admissions, Registration and Records office no later than 5 p.m. No postmark date allowed, no exceptions. No incomplete or late submissions will be considered. Please note: This application is for a restricted entry program and must be hand signed and submitted along with supporting documents and payment. People requiring accommodations due to disability should contact the Disability Services Office at or Submit by Mail: Mt. Hood Community College Admissions, Registration and Records Physical Therapist Assistant SE Stark St Gresham OR Submit in Person: Student Services (room AC2253, Gresham Campus) DO NOT include this page with your application documents.

2 APPLICATION PACKET CHECKLIST Applicant Name: Date: MHCC ID: Every item on this checklist must be received by the application deadline of Friday, March 30, 2018, 5 p.m. Only complete applications containing all the required documents will be considered for review. Incomplete or late applications will not be considered. It is the applicant s full responsibility to make sure everything was received by the deadline. By signing below, I am confirming each item below is included with my application or I have confirmed they are already on file at MHCC. I understand it is my sole responsibility to submit the required documents, and I will not be given notice if my application is incomplete until after the deadline, at which time it will be too late to submit missing documents. 1. General Admissions Application, Apply Online at my.mhcc.edu/ics/admissions and select General Studies as your major. It will change to Physical Therapy Assistant if/when you are admitted to the program. 2. Application Packet Checklist Page 2 3. Verification of Work/Observation Experience, Signed by each clinician that was shadowed or worked with Page 3 4. Admission Criteria Worksheet Page 4 5. PTA Program Acknowledgment Form, Signed Page 5 and 6 6. $25 Application Fee Make check payable to MHCC. Bank card/cash is only payable in person in Student Services (Room AC2253). 7. Official (in a sealed envelope) College Transcript(s) from ALL schools attended. Do not include an MHCC transcript. Courses may be in progress at the time of application submission but must be completed by the end of Winter term, March An updated transcript showing posted grades for the required coursework must be received by the application deadline. List all official transcripts in first column below: q Being Mailed q Included q On File at MHCC Have you applied to this program previously and been selected as an alternate? q No q Yes (Year selected as an alternate: ) q Being Mailed q Included q On File at MHCC q Being Mailed q Included q On File at MHCC Have you previously been dismissed from any other health professions program? q No q Yes (include school name, program, and dates attended): 1. I understand MHCC s Admissions, Registration and Records office will send all application notifications by . It is my responsibility to set my spam filter system to accept addresses even if I am currently receiving s from MHCC. MHCC cannot be responsible for notices which are not received due to spam or junk mail handling. I will make sure to add MHCC to my safe senders list. MHCC recommends applicants to check their on a computer and NOT on a smart phone. Provide the address to be used for application notices: 2. I understand it is my responsibility to ensure all items are received by the application deadline and only complete applications will be evaluated for admission. Furthermore, I have read and understand the admission requirements and procedures for applying. I understand that withholding information or giving untruthful answers to questions on this application could be cause for non-acceptance or dismissal from the program. SIGNATURE: DATE: Mt. Hood Community College Rvsd p. 2 of 6

3 VERIFICATION OF WORK/OBSERVATION EXPERIENCE Applicant Name: Date: MHCC ID: This Form Must Be Filled Out Completely and Submitted as Part of a Complete Application. Physical Therapy Observation or Work Experience Guidelines Ø Experience must have occurred within the past 5 years. Ø Completion of at least 20 hours of work experience or observation. Ø Please note that strong candidates are those who have gained some exposure to the physical therapy field in a variety of settings, and have more than the minimum 20 hours (no more than 60 hours required for application purposes). Setting types include sites such as out-patient clinics, hospitals, nursing homes, schools, or home health agencies. Ø You may make copies of this page if you attended more than three sites. 1. Name of facility or clinic Type of Facility * Example: SNF PT or PTA contact NAME AND THEIR SIGNATURE Name (Please print above) PT or PTA license number AND issuing state Dates and total hours of work or observation at this site 2. Signature of PT or PTA Name (Please print above) 3. Signature of PT or PTA Name (Please print above) Signature of PT or PTA * IP = Hospital or acute rehab SNF = Nursing home PEDS = School system or OP = Out-patient clinic HH = Home health pediatric practice Total Your Hours Here Have you ever held a professional license in the medical field or another discipline? Please list any and all previously licenses held and indicate the current status of license (active/current, lapsed/expired, or revoked). State License No. License Type Expiration / Lapse Date / Revoke Date Explanation / Comments In case of the need to apply again, applicants should keep a copy of this page. Application materials will not be returned to the student. Mt. Hood Community College Rvsd p. 3 of 6

4 ADMISSION CRITERIA WORKSHEET Applicant Name: Date: MHCC ID: This Form Must Be Filled Out Completely and Submitted as Part of a Complete Application. Guidelines: Courses must be completed by the end of Winter term, March Anatomy & Physiology (A&P) classes, including labs, cannot be completed prior to September Math and Writing coursework does not expire. Applicants must have a combined GPA of 3.0 or higher in their A&P classes, including labs. All courses must be taken for a letter grade. College courses taken as pass/fail, satisfactory/unsatisfactory or audit do not fulfill admission criteria for the PTA program. Fill out the form in its entirety. No points will be awarded if the class is not fully documented below. List the courses as they appear on your transcript. For courses not taken at MHCC, do not use the MHCC equivalency, convert to quarter credits, or include +/- on your grades (i.e., B- = B). If the class is currently in progress, put IP in the term/year box. Submit updated official transcripts documenting your grade before the application deadline. You may submit your application with coursework in progress for winter term. Official transcripts (in a sealed envelope or via secure electronic delivery service) from all institutions you have attended must be attached to this application or be on file in the Admissions, Registration & Records office. DO NOT submit your MHCC transcript. PREREQUISITE COURSEWORK REQUIREMENT 1 (No point awarded) Course Term/Year Grade Institution EXAMPLE COURSE: WR121 WR121 WI11 B MHCC MTH065 Beginning Algebra ll or higher WR121 English Composition or higher PREREQUISITE COURSEWORK REQUIREMENT 2 (Up to 20 points awarded) Course Term/Year Grade Credits Grade Points Institution EXAMPLE COURSE: BI121 BI121 WI11 A 4 4x4 =16 MHCC BI121 Essentials of Anatomy and Physiology I BI122 Essentials of Anatomy and Physiology II OR Completion of an anatomy & physiology series equal to or higher than BI121 & BI122. Labs must be included. List courses below. (Ex. BI 231, BI 232 & BI 233) For the purpose of calculating your GPA: A=4, B=3, C=2 Total Number of Credits = Total Grade Points = Grade point total: / Total number of credits: = My GPA: You are not eligible to apply if your above GPA for A&P is under a 3.0. Mt. Hood Community College Rvsd p. 4 of 6

5 Physical Therapist Assistant Program Acknowledgement Form The Oregon Physical Therapist Licensing Board (OPTLB) regulates the practice of physical therapy in Oregon. Oregon Administrative Rules (OAR) indicate that the following conditions are grounds for refusal to grant a PTA license to an applicant who: Is not a person of good moral character as provided in OAR (2)(i); Willfully made a false statement on the application; Failed to disclose requested information or provided false or materially misleading information during the process of applying for a license; Has practiced physical therapy without a license or has purported to be a therapist in violation of ORS ; Has a mental, emotional or physical condition which impairs the applicant s ability or competency to practice physical therapy in a manner consistent with the public health and safety; Has an addiction to or a dependency on alcohol, legend drugs or controlled substances which impairs the applicant s ability or competency to practice physical therapy in a manner consistent with the public health and safety; Has been disciplined or had an application for licensure refused by another Oregon state licensing board or out-of-state licensing board for an act which if committed in Oregon would be grounds for discipline under ORS or OAR ; Has been convicted of violating any federal law or state law relating to controlled substances, subject to the provisions of ORS (2); or Has been convicted of any crime that is a felony or misdemeanor under the laws of any state or of the United States, subject to the provisions of ORS (2). Students are required to answer the professional license background questions below prior to enrolling in the PTA program. You must write in the word Yes or No for each question below. 1. Have you ever been investigated, disciplined, or denied licensure by any governmental licensing agency or authority in any jurisdiction, state, or foreign country? 2. Have you ever surrendered any professional health care license or certificate in any state, jurisdiction or foreign country? I acknowledge that I have been informed of the grounds for refusal to grant a PTA license by the Oregon Physical Therapist Licensing Board and that the statements and information provided above are true and correct in every respect. Full Name (Print) Signature Date MHCC ID Mt. Hood Community College Rvsd p. 5 of 6

6 Physical Therapist Assistant Program Administrative Requirements Acknowledgement Form Students are required to meet the following administrative requirements prior to enrolling in the Physical Therapist Assistant (PTA) Program. Acceptance into the PTA Program is conditional pending completion of the following requirements. Accepted students will be provided with the Health and Safety Documentation Checklist which has details for when and how to complete these requirements. Immunizations: Evidence requires documented receipt of vaccine or documented immunity via titer per CDC guidelines. Measles, mumps and rubella (MMR) Tetanus, diphtheria, pertussis (Tdap) Varicella Hepatitis B (1 st and 2 nd vaccine) Screenings: Tuberculosis (TB) 2-step PPD skin test or QuantiFERON TB Gold blood test Criminal Background Check: Must include Social Security Number trace, state/national criminal background history, sex offender registry check, and OIG LEIE check. Trainings: Basic Life Support (BLS) for Healthcare Providers (must be American Heart Association training) Basic First Aid (training from any provider) Major Medical Insurance: Proof of Major Medical Insurance I acknowledge that I must complete the above requirements by the due dates listed on the Physical Therapist Assistant Program Health and Safety Documentation Checklist in order to be formally admitted to the PTA Program. If I fail to comply with these requirements, I will NOT be admitted to the PTA Program. Full Name (Print) Signature Date MHCC ID Received Date: For Office Use Only: Received By: Mt. Hood Community College Rvsd p. 6 of 6

PHYSICAL THERAPIST ASSISTANT PROGRAM ADMISSION INFORMATION

PHYSICAL THERAPIST ASSISTANT PROGRAM ADMISSION INFORMATION PHYSICAL THERAPIST ASSISTANT PROGRAM ADMISSION INFORMATION 2018 Cohort NOTES Updated November 2017 PTA Program Admission Information Booklet Page 2 TABLE OF CONTENTS Abbreviations... 3 Introduction...

More information

Application Instructions for:

Application Instructions for: Regular Mailing Address Courier Delivery Address Application Instructions for: MASSAGE THERAPIST LICENSURE FOR EXISTING PRACTITIONERS USE THIS APPLICATION ONLY IF YOU WERE AN EXITISTING PRACTITIONER ON

More information

Admission Packet Physical Therapist Assistant Program September 2017 for Class of 2020 Applicants

Admission Packet Physical Therapist Assistant Program September 2017 for Class of 2020 Applicants Dear Prospective Physical Therapist Assistant Student: Admission Packet Physical Therapist Assistant Program September 2017 for Class of 2020 Applicants Thank you for your interest in our Physical Therapist

More information

Musculoskeletal Sonography Certificate Admissions Requirements

Musculoskeletal Sonography Certificate Admissions Requirements Musculoskeletal Sonography Certificate Admissions Requirements Applicants must hold an approved credential or have graduated from an accredited sonography program or have a professional licensure to apply

More information

Musculoskeletal Sonography Application Requirements

Musculoskeletal Sonography Application Requirements Musculoskeletal Sonography Application Requirements Entry Spring 2018 MUSCULOSKELETAL SONOGRPAHY APPLICATION REQUIREMENTS Below are the general admissions requirements for all health programs followed

More information

IMMUNIZATION AND MEDICAL HISTORY FORM

IMMUNIZATION AND MEDICAL HISTORY FORM HEALTH SCIENCES GRADUATE STUDENTS IMMUNIZATION AND MEDICAL HISTORY FORM THIS IS REQUIRED INFORMATION Complete this form and return by November 1 st to: STUDENT HEALTH SERVICES 2040 Campus Box Elon, NC

More information

North Carolina Board of Physical Therapy Examiners Application for Physical Therapist Licensure

North Carolina Board of Physical Therapy Examiners Application for Physical Therapist Licensure FOR OFFICIAL USE ONLY Name: End: Ex: Rev by End: Exost: Board Approved by: PT Endorsement Application Examination Date: / / ID Number: / / Exam Form Number: / / SCORES: Scaled: / / Raw: / / NC Passing:

More information

HOFSTRA UNIVERSITY DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES

HOFSTRA UNIVERSITY DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES HOFSTRA UNIVERSITY DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES Date: March 15, 2017 To: Class of 2019 Re: Health Clearance Forms for Didactic Year Please visit your primary health care provider to complete

More information

Health Careers and Nursing Immunization and Health Requirement Form

Health Careers and Nursing Immunization and Health Requirement Form SEE THE ACCOMPANYING HEALTH REQUIREMENT COMPLETION GUIDE FOR STEP BY STEP INSTRUCTIONS = DENOTES ANNUAL REQUIREMENT TITERS ARE REQUIRED FOR BOTH MMR (MEASLES-MUMPS-RUBELLA) AND VARICELLA MMR TITER DATE:

More information

Matriculating / College of Allied Health Medical Laboratory Science DISTANCE LEARNING

Matriculating / College of Allied Health Medical Laboratory Science DISTANCE LEARNING University of Cincinnati PO Box 670460 Cincinnati OH 45267-0460 Holmes Building Phone (513) 584-4457 Fax (513) 584-2222 TO: FROM: RE: Matriculating / College of Allied Health Medical Laboratory Science

More information

Keiser University Health Forms. Student Name: D.O.B. / /

Keiser University Health Forms. Student Name: D.O.B. / / These forms must be returned to Sentry MD. DO NOT RETURN THESE FORMS TO KEISER UNIVERSITY. Please return forms to Sentry MD, by emailing them as ONE PDF ATTACHMENT to Keiser@SentryMD.com or fax to 817-251-9593

More information

PENNSYLVANIA INSTITUTE OF TECHNOLOGY PHYSICAL THERAPIST ASSISTANT PROGRAM ADMISSIONS PACKET

PENNSYLVANIA INSTITUTE OF TECHNOLOGY PHYSICAL THERAPIST ASSISTANT PROGRAM ADMISSIONS PACKET PENNSYLVANIA INSTITUTE OF TECHNOLOGY PHYSICAL THERAPIST ASSISTANT PROGRAM ADMISSIONS PACKET Kelly Thompson, M.S., PTA, ATC Program Manager kelly.thompson@pit.edu Charles Hewlings, PT, M.Ed, ATC Academic

More information

Sport and Exercise Science Undergraduate Practicum Application Packet Instructions

Sport and Exercise Science Undergraduate Practicum Application Packet Instructions Sport and Exercise Science Undergraduate Practicum Application Packet Instructions Please read the ENTIRE instructions and information sheets carefully for complete directions and information before completing

More information

Health Careers and Nursing Immunization and Health Requirement Completion Guide

Health Careers and Nursing Immunization and Health Requirement Completion Guide Health Careers and Nursing Immunization and Health Requirement Completion Guide Table of Contents HEALTH CAREERS AND NURSING OVERVIEW... 2 TITERS AND IMMUNIZATIONS... 3 MMR Titer (Measles, Mumps, Rubella)...

More information

Henry Ford Hospital Diagnostic Medical Sonography Program

Henry Ford Hospital Diagnostic Medical Sonography Program Revised February 2017 Henry Ford Hospital Diagnostic Medical Sonography Program Application for Admission Do not complete this form until you have read the Admission Standards statement. Additional documentation,

More information

Dental Hygiene Program Associate in Science

Dental Hygiene Program Associate in Science Dental Hygiene Program Associate in Science The Riverside Community College District complies with all federal and state rules and regulations and does not discriminate on the basis of ethnic group identification,

More information

ADMISSIONS POLICIES ADMISSIONS CRITERIA

ADMISSIONS POLICIES ADMISSIONS CRITERIA ADMISSIONS CRITERIA ADMISSIONS POLICIES The Louisiana College PTA program selects a maximum of 24 students each year to enroll in the technical education component of the program. To ensure that the PTA

More information

Clinical Passport Tutorial

Clinical Passport Tutorial What is a Clinical Passport? The Clinical Passport is a set of standard health and safety standards required of all students and faculty caring for patients in the healthcare setting. It serves as a record

More information

Your completed Health Record and any laboratory results must be uploaded to the Student Health Portal at: shac.usciences.edu

Your completed Health Record and any laboratory results must be uploaded to the Student Health Portal at: shac.usciences.edu Box 23; 600 South 43rd Street; Philadelphia PA 19104 Phone: (215) 596-8980 2017-2018 STUDENT HEALTH RECORD SUMMER/FALL 2017 DUE DATE: AUGUST 4, 2017 Your Student Health Record is to be completed and submitted

More information

EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS

EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS PHYSICAL EXAMINATION AND IMMUNIZATION REQUIREMENTS In order to comply with the Texas Administrative Code (Title 25 Health

More information

ST CHRISTOPHER IBA MAR DIOP COLLEGE OF MEDICINE

ST CHRISTOPHER IBA MAR DIOP COLLEGE OF MEDICINE PART 1 HEALTH HISTORY: Answer yes or no. If the question below is yes, provide names and addresses of all physicians or healthcare providers who participated in the diagnosis, referral or treatment. Give

More information

131. Public school enrollees' immunization program; exemptions

131. Public school enrollees' immunization program; exemptions TITLE 14. EDUCATION PART I. FREE PUBLIC SCHOOLS CHAPTER 1. DEPARTMENT OF EDUCATION SUBCHAPTER II. POWERS AND DUTIES 14 Del. C. 131 (2007) 131. Public school enrollees' immunization program; exemptions

More information

RE-REGISTRATION FORM

RE-REGISTRATION FORM RE-REGISTRATION FORM (please print) Name of Child: Male / Female Home Phone #: street city/state/zip Date of Birth: E-mail address: Second e-mail: Mother s Social Security #: Employer s Father s Social

More information

Definition of Practice of Massage Therapy - Education Law, Section 7801

Definition of Practice of Massage Therapy - Education Law, Section 7801 License Requirements Definition of Practice General Requirements Fees Partial Refunds Education Requirements Examination Requirement Applicants Licensed in Another Jurisdiction (Endorsement) Limited Permits

More information

APPLICATION TO EMPLOY A

APPLICATION TO EMPLOY A STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY ARNOLD SCHWARZENEGGER, Governor BOARD OF PSYCHOLOGY 2005 Evergreen Street, SUITE 1400 SACRAMENTO, CA 95815-3831 (916) 263-2699 ext. 3303 www.psychboard.ca.gov

More information

Signature of student Date Signature of parent or guardian (if student is a minor) Date

Signature of student Date Signature of parent or guardian (if student is a minor) Date Frances M. Maguire School of Nursing and Health Professions MEDICAL HISTORY/PHYSICAL EXAMINATION RECORD This form and requirements must be completed between July 1, 2014 and August 22, 2015 Please read

More information

UNIVERSITY OF WISCONSIN-MADISON SCHOOL OF PHARMACY. Health Policies

UNIVERSITY OF WISCONSIN-MADISON SCHOOL OF PHARMACY. Health Policies UNIVERSITY OF WISCONSIN-MADISON SCHOOL OF PHARMACY Health Policies PharmD students are at higher risk than the general population for acquiring communicable diseases such as measles, mumps, rubella, chickenpox,

More information

YMCA School Age Programs 2017

YMCA School Age Programs 2017 YMCA School Age Programs 2017 Child Information Forms Today s / / Please check the session your child will attend: AM only PM only AM and PM Part-time 5 visit AM PM Child s First Name MI Last Name Male

More information

Dental Hygiene. Application Packet & Admissions Information

Dental Hygiene. Application Packet & Admissions Information Dental Hygiene Application Packet & Admissions Information Students interested in the Dental Hygiene program are encouraged to call the Dental Hygiene Department with any questions regarding their admission

More information

Preadmission Health History and P hysical for NOVA Nursing Programs

Preadmission Health History and P hysical for NOVA Nursing Programs Preadmission Health History and P hysical for NOVA Nursing Programs Form 125-017 Rev. 6/2016 INSTRUCTIONS TO STUDENT: This form must be filled out by applicant and a licensed primary care provider: physician,

More information

HOWARD UNIVERSITY STUDENT HEALTH CENTER. Checklist of Immunizations/TB tests/medical History/Physical Exam

HOWARD UNIVERSITY STUDENT HEALTH CENTER. Checklist of Immunizations/TB tests/medical History/Physical Exam Checklist of Immunizations/TB tests/medical History/Physical Exam Note: this checklist must be submitted with the immunization/tb testing forms Please complete ALL of the requirements below and check off

More information

DENTAL HYGIENE LICENSURE BY CREDENTIALS

DENTAL HYGIENE LICENSURE BY CREDENTIALS LOUISIANA STATE BOARD OF DENTISTRY 365 CANAL PLACE, SUITE 2680 NEW ORLEANS, LOUISIANA 70130 PHONE: 504-568-8574 ~ FAX: 504-568-8598 www.lsbd.org DENTAL HYGIENE LICENSURE BY CREDENTIALS Applying for a license

More information

Sandra Pence, MS, RDH Professor and Program Director UAA Dental Hygiene Program Office: AHS 148D (907)

Sandra Pence, MS, RDH Professor and Program Director UAA Dental Hygiene Program Office: AHS 148D (907) P a g e 1 Sandra Pence, MS, RDH Professor and Program Director UAA Dental Hygiene Program Office: AHS 148D (907) 786-6925 pence@uaa.alaska.edu Introduction: Thank you for your interest in the UAA Dental

More information

APPLICATION FOR CLINICAL OBSERVERS - University of California, San Francisco

APPLICATION FOR CLINICAL OBSERVERS - University of California, San Francisco APPLICATION F CLINICAL OBSERVERS - University of California, San Francisco SECTION 1: To be completed by student and authorized official of student s school. Please return all copies to the Department

More information

Immunisation Declaration Form - Version 2

Immunisation Declaration Form - Version 2 All students undertaking an award within Institute of Health & Nursing Australia with a clinical/work experience placement component are required to ensure immunisations are up to date. Please read the

More information

PLEASE MAIL APPLICATION AND ORIGINAL TRANSCRIPTS TO: Lamar Institute of Technology

PLEASE MAIL APPLICATION AND ORIGINAL TRANSCRIPTS TO: Lamar Institute of Technology Lamar Institute of Technology Allied Health Department Dear Applicant: Thank you for considering LIT s Diagnostic Medical Sonography Program for your education and career. Attached please find all necessary

More information

ARAPAHOE COMMUNITY COLLEGE

ARAPAHOE COMMUNITY COLLEGE ARAPAHOE COMMUNITY COLLEGE Physical Therapist Assistant Program Department Chair: Paula Provence 303.797.897 Email: Paula.Provence@arapahoe.edu Program Information Thank you for your interest in the Physical

More information

Article X School Health Immunization

Article X School Health Immunization Allegheny County Health Department Rules and Regulations ALLEGHENY COUNTY HEALTH DEPARTMENT RULES AND REGULATIONS ARTICLE X. SCHOOL HEALTH IMMUNIZATION 1001. PURPOSE AND SCOPE. This subchapter has been

More information

PLEASE MAIL APPLICATION AND ORIGINAL TRANSCRIPTS TO: Lamar Institute of Technology

PLEASE MAIL APPLICATION AND ORIGINAL TRANSCRIPTS TO: Lamar Institute of Technology Lamar Institute of Technology Allied Health Department Dear Applicant: Thank you for considering LIT s Diagnostic Cardiac (Echocardiography) Sonography Program for your education and career. Attached please

More information

Penn State New Kensington Radiological Sciences Program Physical Examination

Penn State New Kensington Radiological Sciences Program Physical Examination Penn State New Kensington Radiological Sciences Program Physical Examination Personal Information (Student information) First Name: Middle Name: Last Name: Sex: Date of Birth (mm/dd/yyyy): Address: City:

More information

2018 National ASL Scholarship

2018 National ASL Scholarship Eligibility Statement 2018 National ASL Scholarship Deadline: May 11, 2018 High school seniors planning to major or minor in American Sign Language, Deaf Studies, Deaf Education, or Interpreter Preparation

More information

Utah s Immunization Rule Individual Vaccine Requirements

Utah s Immunization Rule Individual Vaccine Requirements Utah s Immunization Rule Individual Vaccine Requirements Which vaccines are required for school entry in Utah? Grades K-6: 5 doses DTaP (4 doses if the 4 th dose was given after the 4 th birthday) 4 doses

More information

National Association of Forensic Counselors

National Association of Forensic Counselors NAFC MEMBERSHIP APPLICATION FOR ADDICTIONS SPECIALTIES Thank you for your interest in NAFC Membership. If you have any questions pertaining to this application, please contact us and we will assist you

More information

Congratulations on your admission to Samuel Merritt University. Welcome to the SHAC! (Student Health and Counseling)

Congratulations on your admission to Samuel Merritt University. Welcome to the SHAC! (Student Health and Counseling) Samuel Merritt University Student Health And Counseling (SHAC) Peralta Medical Office Building 3100 Telegraph Avenue, Suite 3105 Oakland, CA 94609 Telephone (510) 869-6629 Congratulations on your admission

More information

Sibley Volunteers How to Apply

Sibley Volunteers How to Apply Sibley Volunteers How to Apply Thank you for your interest in becoming a Volunteer at Sibley Memorial Hospital. Please read the guidelines and rules that apply to Volunteers. All application forms should

More information

Title 32: PROFESSIONS AND OCCUPATIONS

Title 32: PROFESSIONS AND OCCUPATIONS Title 32: PROFESSIONS AND OCCUPATIONS Chapter 45-A: PHYSICAL THERAPIST PRACTICE ACT Table of Contents Section 3111. DEFINITIONS... 3 Section 3111-A. SCOPE OF PRACTICE... 3 Section 3112. BOARD CREATED;

More information

Dental Hygiene Program Information Packet A.A.S. Degree

Dental Hygiene Program Information Packet A.A.S. Degree Dental Hygiene Program Information Packet A.A.S. Degree This Information Packet provides the prospective applicant with information about the Dental Hygiene Program admission process at Montgomery County

More information

PHYSICAL MEDICINE AND REHABILITATION CSHCN SERVICES PROGRAM PROVIDER MANUAL

PHYSICAL MEDICINE AND REHABILITATION CSHCN SERVICES PROGRAM PROVIDER MANUAL PHYSICAL MEDICINE AND REHABILITATION CSHCN SERVICES PROGRAM PROVIDER MANUAL NOVEMBER 2017 CSHCN PROVIDER PROCEDURES MANUAL NOVEMBER 2017 PHYSICAL MEDICINE AND REHABILITATION Table of Contents 30.1 Enrollment......................................................................

More information

SOUTH TEXAS COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM FREQUENTLY ASKED QUESTIONS

SOUTH TEXAS COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM FREQUENTLY ASKED QUESTIONS SOUTH TEXAS COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM FREQUENTLY ASKED QUESTIONS Contents FAQs... 2 What Is A Physical Therapist Assistant?... 2 Do I Need A License To Be A PTA In Texas?... 2 What Are

More information

RADIOLOGIST ASSISTANT MASTER S PROGRAM APPLICANT PROCEDURES & CHECK LIST

RADIOLOGIST ASSISTANT MASTER S PROGRAM APPLICANT PROCEDURES & CHECK LIST RADIOLOGIST ASSISTANT MASTER S PROGRAM APPLICANT PROCEDURES & CHECK LIST APPLICATION PROCEDURES Please read the following procedures carefully. All applicants must submit the items listed in the checklist

More information

1 P a g e. To Whom It May Concern:

1 P a g e. To Whom It May Concern: 1 P a g e To Whom It May Concern: The Board of Directors and Medical Advisory Committee of the National Lymphedema Network (NLN ) are pleased that you are interested in becoming an NLN Affiliate Training

More information

CITY OF ARCADIA MASSAGE THERAPIST APPLICATION PACKET

CITY OF ARCADIA MASSAGE THERAPIST APPLICATION PACKET CITY OF ARCADIA MASSAGE THERAPIST APPLICATION PACKET Arcadia City Hall Arcadia Police Department 240 W Huntington Dr 250 W Huntington Dr Arcadia CA 91007 Arcadia CA 91007 626-574-5430 626-574-5150 Thank

More information

Date of Birth Soc. Sec. or UD ID # Month Day Year. Country of Birth If not USA, indicate when you entered this country M/Y

Date of Birth Soc. Sec. or UD ID # Month Day Year. Country of Birth If not USA, indicate when you entered this country M/Y University of Delaware-Student Health Service, Laurel Hall, Newark, Delaware 19716-8101 Telephone: 302/831-2226 Fax: 302/831-6407 IMMUNIZATION DOCUMENTATION ALL OF THE FOLLOWING INFORMATION MUST BE COMPLETED

More information

Substance Abuse Policy. Substance Abuse Policy for Employees and Students

Substance Abuse Policy. Substance Abuse Policy for Employees and Students College Rules and Regulations 2.2008.1 Substance Abuse Policy Substance Abuse Policy for Employees and Students I. Substance Abuse Policy for Employees and Students A. Purpose The County College of Morris

More information

WASHBURN UNIVERSITY SCHOOL OF APPLIED STUDIES. PHYSICAL THERAPIST ASSISTANT PROGRAM Admissions Criteria

WASHBURN UNIVERSITY SCHOOL OF APPLIED STUDIES. PHYSICAL THERAPIST ASSISTANT PROGRAM Admissions Criteria WASHBURN UNIVERSITY SCHOOL OF APPLIED STUDIES PHYSICAL THERAPIST ASSISTANT PROGRAM Admissions Criteria ADMISSION REQUIREMENTS Deadline for completed applications is February 1 st of the application year.

More information

Metropolitan Community College- Penn Valley Physical Therapist Assistant Program Application

Metropolitan Community College- Penn Valley Physical Therapist Assistant Program Application Metropolitan Community College- Penn Valley Physical Therapist Assistant Program Application Accredited by: ATTENTION Beginning with the June 10 th application for both PTA programs there is a new requirement

More information

School Year ALASKA CHILD CARE & SCHOOL IMMUNIZATION REQUIREMENT CHANGES

School Year ALASKA CHILD CARE & SCHOOL IMMUNIZATION REQUIREMENT CHANGES 2009 2010 School Year ALASKA CHILD CARE & SCHOOL IMMUNIZATION REQUIREMENT CHANGES EFFECTIVE JULY 1, 2009 ALASKA IMMUNIZATION PROGRAM (907) 269-8000 OR 1-888-430-4321 Varicella: Immunization Documentation

More information

NATIONAL CERTIFICATE IN TOBACCO TREATMENT PRACTICE (NCTTP) TEST EXEMPTION OFFER APPLICATION VALID: OCTOBER 15, APRIL 15, 2018

NATIONAL CERTIFICATE IN TOBACCO TREATMENT PRACTICE (NCTTP) TEST EXEMPTION OFFER APPLICATION VALID: OCTOBER 15, APRIL 15, 2018 NATIONAL CERTIFICATE IN TOBACCO TREATMENT PRACTICE (NCTTP) TEST EXEMPTION OFFER APPLICATION VALID: OCTOBER 15, 2017 - APRIL 15, 2018 I. Personal Information Name: Home Address: City: State/Province: Country:

More information

January, Dear Friend of Camp Sunrise,

January, Dear Friend of Camp Sunrise, At the Warwick Conference Center, P.O. Box 349, 62 Warwick Center Road, Warwick, NY 10990 Phone: 845-986-1164 / Fax: 845-986-8874 / Email: warwickcc@optimum.net January, 2017 Dear Friend of Camp Sunrise,

More information

Medical gap arrangements - practitioner application

Medical gap arrangements - practitioner application Medical gap arrangements - practitioner application For services provided in a licensed private hospital or day hospital facility (Private Hospital) only. Please complete this form to apply for participation

More information

Workforce-Education/Physical-Therapist-Assistant

Workforce-Education/Physical-Therapist-Assistant PHYSICAL THERAPIST ASSISTANT PROGRAM FACT SHEET AND APPLICATION PACKET Program Website: PTA Program Email: www.odessa.edu/programs/career-technical-and- Workforce-Education/Physical-Therapist-Assistant

More information

American Physical Therapy Association Credentialed Clinical Instructor Program

American Physical Therapy Association Credentialed Clinical Instructor Program American Physical Therapy Association Credentialed Clinical Instructor Program Co-sponsored by: University of Wisconsin-La Crosse Physical Therapy Program & American Physical Therapy Association Thursday,

More information

UNIVERSITY OF UTAH INTERNATIONAL TRAVEL CLINIC Phone: Fax: N Medical Dr. Salt Lake City, UT 84132

UNIVERSITY OF UTAH INTERNATIONAL TRAVEL CLINIC Phone: Fax: N Medical Dr. Salt Lake City, UT 84132 Welcome to UNIVERSITY OF UTAH INTERNATIONAL TRAVEL CLINIC Phone: 801-801-581-2898 Fax: 801-585-7315 50 N Medical Dr. Salt Lake City, UT 84132 Our goal is to help you have a safe and enjoyable experience

More information

Peer Mentor Program Application

Peer Mentor Program Application University of South Florida Peer Mentor Program Application College of Arts and Sciences 2/3/2016 WELCOME LETTER Thank you for your interest in becoming a USF College of Arts and Sciences Peer Mentor.

More information

NEW PROVIDER ENROLLMENT FOR ADULT SITE

NEW PROVIDER ENROLLMENT FOR ADULT SITE New Jersey Department of Health Vaccines for Children (NJVFC) Program P.O. Box 369 Trenton, NJ 08625-0369 Phone: (609) 826-4862 Fax: (609) 826-4868 INSTRUCTIONS: Email completed New Provider Enrollment

More information

Connecticut State University Student Health Services Form Instructions

Connecticut State University Student Health Services Form Instructions Connecticut State University Student Health Services Form Instructions Important: Prior to submitting your information, please make a copy for your records Connecticut General Statute and CCSU requires

More information

CALHOUN COMMUNITY COLLEGE HEALTH SCIENCES DIVISION PHYSICAL EXAM

CALHOUN COMMUNITY COLLEGE HEALTH SCIENCES DIVISION PHYSICAL EXAM To the Student: Complete Part I on the Physical Exam Only. CALHOUN COMMUNITY COLLEGE HEALTH SCIENCES DIVISION PHYSICAL EXAM I. Name: Calhoun ID: Program of Study: CLT DAT EMS NUR PTA SUR of Birth: Age:

More information

Student Health Services

Student Health Services MEDICAL RECDS of birth Home address City State ZIP Home phone number Gender identity: Pronouns: Chosen Name Class status (circle): First year Sophomore Junior Senior Graduate Postbac Premed IN CASE OF

More information

New patients approved for the Novo Nordisk PAP may only be eligible for insulin vials. For a full list of available products, please visit:

New patients approved for the Novo Nordisk PAP may only be eligible for insulin vials. For a full list of available products, please visit: The Novo Nordisk Diabetes Patient Assistance Program (PAP) provides medication to qualifying applicants at no charge. If the applicant qualifies under the Novo Nordisk Diabetes PAP guidelines, a 120-day

More information

Academic Year

Academic Year Academic Year 2016-2017 To Prospective Dental Hygiene Students: Dental Hygiene is an exciting career for an individual to pursue. As a member of the oral health team, the dental hygienist has the unique

More information

DENTAL HYGIENE PROGRAM Revised June School of Health Sciences DENTAL HYGIENE. Program Packet

DENTAL HYGIENE PROGRAM Revised June School of Health Sciences DENTAL HYGIENE. Program Packet School of Health Sciences DENTAL HYGIENE Program Packet The Application Process Must Be Completed By MARCH 1 ST Of Each Application Year. School of Health Sciences, MP458 909 S. Boston Ave. Tulsa, Oklahoma

More information

Certification Guidelines: Credential Standards and Requirements Table

Certification Guidelines: Credential Standards and Requirements Table Certification Guidelines: Credential Standards and Requirements Table Certified Recovery Peer Specialist (CRPS) Define Yourself as a Professional through Certification. 1715 S. Gadsden St. Tallahassee,

More information

Bachelor of Science Degree in PTA Admission Information Packet & Forms Deadline: Jan. 15 or May 1, 2018 Start: Fall 2018

Bachelor of Science Degree in PTA Admission Information Packet & Forms Deadline: Jan. 15 or May 1, 2018 Start: Fall 2018 Bachelor of Science Degree in PTA Admission Information Packet & Forms Deadline: Jan. 15 or May 1, 2018 Start: Fall 2018 We are pleased to hear of your interest in advancing your degree and career as a

More information

Immunisation Requirements and Mandatory Health Screenings

Immunisation Requirements and Mandatory Health Screenings Immunisation Requirements and Mandatory Health Screenings The purpose of pre-employment screening is to ensure that you are fit for the position you have applied for and that you don t have any condition

More information

(A) results from that individual's participation in or training for sports, fitness training, or other athletic competition; or

(A) results from that individual's participation in or training for sports, fitness training, or other athletic competition; or VT AT Act 12/04 Title 26: Professions and Occupations Chapter 83: ATHLETIC TRAINERS 4151. Definitions As used in this chapter: (1) "Athlete" means any individual participating in fitness training and conditioning,

More information

Criteria and Application for Men

Criteria and Application for Men Criteria and Application for Men Return completed form via fax or email to LIVESTRONG Foundation attn LIVESTRONG Fertility Fax 512.309.5515 email Cancer.Navigation@LIVESTRONG.org Made possible by participating

More information

DEL MAR COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM ADMISSIONS PROCEDURES

DEL MAR COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM ADMISSIONS PROCEDURES DEL MAR COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM ADMISSIONS PROCEDURES Department of Allied Health (WEST CAMPUS Health Science Building 1, Office 242) 101 Baldwin, Corpus Christi, Texas 78404 Phone:

More information

HIV Rules & Statutes:

HIV Rules & Statutes: January 2005 HIV Rules & Statutes: A GUIDE FOR OREGON HIV SERVICE PROVIDERS AND ADVOCATES First Edition, January 2005 HIV Client Services Program 800 NE Oregon St. Portland, OR 97232 If you would like

More information

I AA P The Indiana Association for Addiction Professionals

I AA P The Indiana Association for Addiction Professionals I AA P The Indiana Association for Addiction Professionals Indiana Association for Addiction Professionals Certification Application I. Personal Data Name Date Address City/State/Zip Phone (w) / (h) /

More information

Continuing Competency Program

Continuing Competency Program Continuing Competency Program Maintaining your Respiratory Care Credentials EXCELLENCE defines 1 us. The NBRC Continuing Competency Program For everyone whose mission involves protecting patient lives

More information

Immunization Requirements for School Entry - Ohio

Immunization Requirements for School Entry - Ohio Immunization Requirements for School Entry - Ohio Kindergarten through 12 th Grade Andrew Heffron Cuyahoga County Board of Health This information will help your school better understand Immunization entry

More information

Vermont Secretary of State Office of Professional Regulation ADMINISTRATIVE RULES FOR LICENSED ACUPUNCTURISTS TABLE OF CONTENTS

Vermont Secretary of State Office of Professional Regulation ADMINISTRATIVE RULES FOR LICENSED ACUPUNCTURISTS TABLE OF CONTENTS Vermont Secretary of State Office of Professional Regulation ADMINISTRATIVE RULES FOR LICENSED ACUPUNCTURISTS TABLE OF CONTENTS PART 1. GENERAL INFORMATION ON LICENSURE OF ACUPUNCTURISTS 1.1 The Purpose

More information

Substantial Equivalency Process for Massage Therapists

Substantial Equivalency Process for Massage Therapists Substantial Equivalency Process for Massage Therapists May 2014 Substantial Equivalency Process Purpose of Substantial Equivalency To provide existing practitioners with an opportunity to best understand

More information

3726 E. Hampton St., Tucson, AZ Phone (520) Fax (520)

3726 E. Hampton St., Tucson, AZ Phone (520) Fax (520) 3726 E. Hampton St., Tucson, AZ 85716 Phone (520) 319-1109 Fax (520)319-7013 Exodus Community Services Inc. exists for the sole purpose of providing men and women in recovery from addiction with safe,

More information

Special Education Fact Sheet. Special Education Impartial Hearings in New York City

Special Education Fact Sheet. Special Education Impartial Hearings in New York City New York Lawyers For The Public Interest, Inc. 151 West 30 th Street, 11 th Floor New York, NY 10001-4017 Tel 212-244-4664 Fax 212-244-4570 TTD 212-244-3692 www.nylpi.org Special Education Fact Sheet Special

More information

TITLE 64 INTERPRETIVE RULE DEPARTMENT OF HEALTH AND HUMAN RESOURCES BUREAU FOR PUBLIC HEALTH

TITLE 64 INTERPRETIVE RULE DEPARTMENT OF HEALTH AND HUMAN RESOURCES BUREAU FOR PUBLIC HEALTH TITLE 64 INTERPRETIVE RULE DEPARTMENT OF HEALTH AND HUMAN RESOURCES BUREAU FOR PUBLIC HEALTH SERIES 95 IMMUNIZATION REQUIRMENTS AND RECOMMENDATIONS FOR NEW SCHOOL ENTERERS 64-95-1. General. 1.1. Scope.

More information

Federation of State Boards of Physical Therapy Jurisdiction Licensure Reference Guide Topic: License Renewal. License Renewal on Birthdays

Federation of State Boards of Physical Therapy Jurisdiction Licensure Reference Guide Topic: License Renewal. License Renewal on Birthdays The table below lists information on the term and renewal date for each jurisdiction. Summary License Term 1 26 2 Renewal Date One date 31 Birthdays 6 Half in even years 4 4 License Term AL AK AZ AR CA

More information

SOCIAL WORK PROGRAM. Field Practicum Application. City: State: Zip:

SOCIAL WORK PROGRAM. Field Practicum Application. City: State: Zip: SOCIAL WORK PROGRAM Field Practicum Application Name: Date: Address: Home Phone: E-Mail Work Phone: K#: Local Street Address or Box #: City: State: Zip: DOB: Marital Status: Driver s License Number and

More information

2005 Evergreen Street, Suite 1550, Sacramento, CA P (916) F (916)

2005 Evergreen Street, Suite 1550, Sacramento, CA P (916) F (916) DENTAL BOARD OF CALIFORNIA 2005 Evergreen Street, Suite 1550, Sacramento, CA 95815 P (916) 263-2300 F (916)263-2347 www.dbc.ca.gov APPLICATION FOR RDA EXAMINATION AND LICENSURE (QUALIFICATION THROUGH SATISFACTORY

More information

Dental Plus of Idaho THE POLICY PROVIDES DENTAL BENEFITS ONLY.

Dental Plus of Idaho THE POLICY PROVIDES DENTAL BENEFITS ONLY. Dental Plus of Idaho THE POLICY PROVIDES DENTAL BENEFITS ONLY. Form No. 005DPID(1/18) The Dental Plus of Idaho plan is a managed care dental policy and is underwritten by: Willamette Dental of Idaho, Inc.

More information

(AIM) Autism/Asperger Initiative at Mercyhurst Foundations Program Application

(AIM) Autism/Asperger Initiative at Mercyhurst Foundations Program Application (AIM) Autism/Asperger Initiative at Mercyhurst Foundations Program Application CONTACT INFORMATION: BRADLEY MCGARRY, Director (AIM) Autism / Asperger Initiative at Mercyhurst 313 B Old Main e-mail bmcgarry@mercyhurst.edu

More information

Candidate and Facilitator Standards Policy

Candidate and Facilitator Standards Policy Candidate and Facilitator Standards Policy Practicing Within the Scope of Existing Licensing, Training and/or Certification: The Daring Way is a curriculum that should be used in conjunction with existing

More information

2017 Certificate Application This application will be accepted through Dec. 31, Fee: $150

2017 Certificate Application This application will be accepted through Dec. 31, Fee: $150 Dental Assisting National Board, Inc. 2017 Certificate Application This application will be accepted through Dec. 31, 2017. Fee: $150 Measuring Dental Assisting Excellence Oregon Expanded Functions Orthodontic

More information

Immunization Documentation Upload instructions

Immunization Documentation Upload instructions Immunization Documentation Upload instructions 1. Log into Health-e-Messaging using your Kerberos ID and password. 2. Enter your student ID number. 3. From the left side of the screen choose either: Immunizations

More information

Legislative Counsel s Digest:

Legislative Counsel s Digest: Senate Bill No. 250 Senator Carlton (by request) CHAPTER... AN ACT relating to dentistry and dental hygiene; revising various provisions governing the qualifications, examination and licensure of dentists

More information

NOTICE: Applicants must be 21 years old by June 14 th, 2014 to enter this process.

NOTICE: Applicants must be 21 years old by June 14 th, 2014 to enter this process. 1 NOTICE: Intent forms and past history questionnaire must be returned to the Milford Police Headquarters-430 Boston Post Road, Milford, CT 06460-No later than 5:00 PM on Friday, June 13th, 2014. Applicants

More information

OVERALL PROGRAM GOALS AND OBJECTIVES

OVERALL PROGRAM GOALS AND OBJECTIVES The McKenzie Institute USA Orthopaedic Residency is accredited by the American Physical Therapy Association as a postprofessional residency program for physical therapists in Orthopaedics. OVERVIEW The

More information

Certified Peer Specialist Training Application

Certified Peer Specialist Training Application Please read the CPS Application Supplement before completing application. Go to http://www.viahope.org/resources/peer-specialist-training-application-supplement This training is intended for individuals

More information

Dental Hygiene. Admission Packet Dundalk. https://dhcas.liaisoncas.com/applicant-ux/#/login

Dental Hygiene. Admission Packet Dundalk.  https://dhcas.liaisoncas.com/applicant-ux/#/login Dental Hygiene Admission Packet 2017-18 Dundalk www.cccmd.edu/shp https://dhcas.liaisoncas.com/applicant-ux/#/login DENTAL HYGIENE Program Description Thank you for your interest in the Dental Hygiene

More information

St. Patrick s Preschool

St. Patrick s Preschool Application for Admission Accepting Children Ages 2 ½ to 5 Years Please Return Forms to St. Patrick Catholic Church Parish House 221 West Nelson Street Lexington (540) 463-3533 Stpatspreschool123@gmail.com

More information