Associate of Applied Science Degree Physical Therapist Assistant Application Fall 2018

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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

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