Physical Therapist Assistant Program Admission Form

DELGADO COMMUNITY COLLEGE IS AN EQUAL OPPORTUNITY FACILITY. DELGADO COMMUNITY COLLEGE DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, GENDER, AGE OR QUALIFIED DISABILITY. SUCCESSFUL ENTRY AS A STUDENT IN THE PHYSICAL THERAPIST ASSISTANT PROGRAM WILL BE BASED UPON THE MERITS OF PAST EDUCATION, EXPERIENCE, RESPONSES TO THE QUESTIONS ON THE APPLICATION FORM AND POSSIBLE INTERVIEW.

Incomplete applications will not be processed.

When you submit your completed application you will receive  a copy of your application in your email. You will include this copy in your PTA Application Packet. Packets are due by March 31, 2021 and must include all of the following: (1) official transcripts from every college you have attended, (2) two Documentation of Experience (DOE) Forms in sealed envelopes with signature of PT/PTA completing DOE forms for you across the seal, (3) completed and signed Technical Standards, and (4) Narrative. Your application will not be accepted unless all forms, including official transcripts from every college attended, are included.

PERSONAL DATA:
EDUCATIONAL DATA:
(Include: name of school, location, grade entered, grade completed, year graduated)
(include: name of school, location, major, month/year started, month/year ended, degree awarded).
Are you presently enrolled in college spring courses?
EMPLOYMENT DATA:
Are you reapplying for this program?
Have you ever been suspended or dismissed from any college or university for academic or disciplinary reasons?
Are you a U.S. Citizen?
Are you a Veteran?
Are you a member of National Guard or reserve?
Have you applied for admission to other Allied Health Programs at Delgado?
Have you ever been charged with, convicted of, pled guilty or no contest, received a suspended sentence or had adjudication withheld in connection with a FELONY or MISDEMEANOR violation of a state or federal statute? Misdemeanor speeding convictions not related to alcohol or drug use are not required to be reported
Are you able to travel 55 miles to clinical practicum site, if necessary?
DOCUMENTATION OF CLINICAL EXPERIENCE (DOE):

List the two PTs or PTAs who will complete your two (2) Documentation of Physical Therapy Experience (DOE) forms. Include the name of PT or PTA who supervised you, phone number or email, name of facility, hours completed. If you are reapplying to the PTA Program submit information and DOE forms ONLY for hours completed since the date of your last application until this application.
PT/PTA name, email and phone number, facility, hours worked

ALL APPLICANTS PLEASE READ CAREFULLY AND SIGN THE FOLLOWING:

I UNDERSTAND THAT THE INFORMATION SUBMITTED ON THIS APPLICATION FOR ADMISSION TO DELGADO COMMUNITY COLLEGE’S ALLIED HEALTH PROGRAM IN MY NAME WILL BE RELIED UPON BY DELGADO COMMUNITY COLLEGE OFFICIALS TO DETERMINE MY STATUS FOR ADMISSION ELIGIBILITY. I AUTHORIZE DELGADO COMMUNITY COLLEGE OFFICIALS TO VERIFY ANY INFORMATION I HAVE PROVIDED. I FURTHER AUTHORIZE ANY AND ALL EDUCATIONAL INSTITUTIONS, GOVERNMENTAL AGENCIES, AND PRIVATE EMPLOYERS THAT I HAVE ATTENDED, WORKED FOR, OR WHO MAINTAIN RECORDS RELATED TO ME TO RELEASE SUCH INFORMATION TO DELGADO COMMUNITY COLLEGE.

I AGREE TO NOTIFY DELGADO COMMUNITY COLLEGE’S ALLIED HEALTH ADMISSIONS OFFICE OF ANY CHANGES TO THE INFORMATION PROVIDED.

I CERTIFY THAT THE INFORMATION IN THIS APPLICATION IS COMPLETE AND CORRECT AND UNDERSTAND THAT SUBMISSION OF FALSE, INCOMPLETE, OR INCORRECT INFORMATION IS GROUNDS FOR REJECTION OF MY APPLICATION, WITHDRAWAL OF ANY ACCEPTANCE OFFER, CANCELLATION OF ENROLLMENT, OR APPROPRIATE DISCIPLINARY ACTION. I UNDERSTAND IT IS ALSO NECESSARY TO COMFORM TO THE PROGRAM’S TECHNICAL STANDARDS AND REQUIREMENTS CONCERNING A PHYSICAL EXAMINATION.  IF ACCEPTED, I AGREE TO ABIDE BY AND OBSERVE ALL PROGRAM AND AFFILIATE HOSPITAL POLICIES, RULES AND REGULATIONS, AS AMENDED FROM TIME TO TIME.

I ALSO UNDERSTAND THAT THIS APPLICATION IS FOR THIS PROGRAM ONLY. IF I ENTER DELGADO COLLEGE, I MUST FILL OUT AND SUBMIT A DELGADO COLLEGE APPLICATION FOR ADMISSION. COMPLETION OF THIS FORM DOES NOT INDICATE THAT YOU ARE ACCEPTED INTO THE PROGRAM.