POLK STATE COLLEGE APPLICATION FOR ACCEPTANCE OCCUPATIONAL THERAPY ASSISTANT PROGRAM. Name: Last First Middle. Former Name(s):

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1 POLK STATE COLLEGE APPLICATION FOR ACCEPTANCE OCCUPATIONAL THERAPY ASSISTANT PROGRAM STUDENT INFORMATION: Name: Last First Middle Former Name(s): Student Identification Number: D.O.B Phone Numbers: Home ( ) Work ( ) Cell ( ) Have you previously been enrolled in an Allied Health program at Polk State College or any other community college that prepares graduates to sit for Licensure or Certification? Yes, at PSC Yes, at another school No If yes, please explain: Yes No Do you hold any health professional licenses or certificates? If yes, indicate type and licensure or certificate number: Occupational Therapy Assistant Are You Ready for Independence?

2 Page 2 The Occupational Therapy Assistant Program is committed to the College's equal access/equal opportunity plan in student admission criteria. If you are currently employed or have recently been employed (within 5 years) by a health care facility/provider, please provide the following information: Other employment: Provide for other employment in past five years: Occupational Therapy Assistant Opportunities for Transformation and Autonomy 2

3 Page 3 LICENSURE INQUIRY/INFORMATION: Florida regulations provide that the denial of a license/certificate may occur if an individual is habitually intemperate, addicted to, or is found to be in illegal possession or involved in the sale of distribution of habit forming drugs, and/or is unfit or incompetent by reason of gross negligence, physical or mental condition or other like causes which could result in behavior that interferes in his/her practice as a health professional. An application for licensure/certification in the State of Florida includes the following questions. A "yes" answer to any question could result in the denial of a license by the State. If your answer to any of the questions is "YES", you must meet with the Program Director of the program prior to the submittal of the application to the program. Be advised that failure to honestly and accurately disclose prior history of convictions and/or felonies in this application will automatically result in your disqualification for admission into the program and/or dismissal from the program. Yes No Have you ever been convicted or have you entered a no contest or guilty plea-regardless of adjudication-offense other than a minor traffic violation? Yes No Have you ever been denied or is there now any proceeding to deny your application for a license to practice a health profession in Florida or any other jurisdiction? Yes No Have you ever had a disciplinary action taken against your license to practice a health profession by the licensing authority in Florida or any other jurisdiction? Yes No Have you ever surrendered a license to practice in a health profession in Florida or any other jurisdiction while any such disciplinary charges were pending against you? I certify that I have read and understand the standards indicated above regarding licensure/certification as a health professional in the State of Florida. Applicant's Signature Date TO BE COMPLETED (IF NECESSARY) BY PROGRAM MANAGER/DIRECTOR I have informed the above-identified applicant regarding the licensing/certification process in the State of Florida in relation to previous criminal convictions. Program Director Date 3

4 Page 4 OBSERVATION HOURS: OTA applicants are required to complete 20 hours of observation in a clinic offering occupational therapy services, and document the experiences on the Observation Hours Form, which needs to be submitted directly to program director upon completion. Observation hours may be waived if you have experience as a Rehab Tech or Allied Health clinician. In order to waive the observation hours, the applicant must follow the following procedures: (Please, check the one that applies to you) If the applicant is/was employed as a Rehab Tech, it is necessary to secure a letter from an occupational therapy clinician certifying that the applicant worked closely with the occupational therapy department, describing the role and type of experiences to which the applicant was exposed at the site. The letter must be written on the company s letterhead and submitted along with the program application form If the applicant is/was an Allied Health clinician, copies of professional credentials need to be submitted along with the program application form. THIS CERTIFICATION IS TO BE COMPLETED BY ALL APPLICANTS I hereby certify that the facts set forth in this application are true and complete to the best of my knowledge. I understand that discovery of any falsification of this information will result in denial of admission or prompt dismissal from the program. Polk State College is hereby authorized during the selection process and/or during my tenure as a student, if admitted, to make any investigation that is deemed necessary concerning the above information with regard to my suitability to practice as a health professional. Applicant's Printed Name Date Applicant's Signature 4

5 Page 5 ADMISSION INTO THE OCCUPATONAL THERAPY ASSISTANT PROGRAM IS CONTINGENT UPON COMPLIANCE WITH THE SPECIFIC REQUIREMENTS LISTED BELOW: 1. A student must submit a complete and accurate application form directly to the OTA Program Director or an academic advisor at any of the College's campuses by October 31 st in order to be considered for admission into the class starting in January of each year. Note: Following recommendations by the OTA Program Advisory Committee, the 24 seats for the January 2013 class will be assigned by the end of November 2011 to the first 24 qualified applicants that were already on the wait list for the January 2012 class. The next 10 qualified applicants will serve as alternates. The remaining applicants on the wait list will be advised to submit a new application to the program (if still interested in applying for the January 2013 class), during the application window. 2. Students applying through the Linkage Program must do so by September 30 th of each year. 3. No application is considered if submitted before or after the admission window. 4. No application is considered until all necessary College admission documentation (application to PSC, high school transcripts, residency paperwork, etc) has been received and processed by the Registrar's Office. 5. Seats in the program are assigned to the first 24 applicants on a first-come-first-qualified basis. Ranking will be based on the date and time stamped on the application form by the academic advisor or program director upon receipt of the form. Ranking for linkage applicants are GPA-based. 6. Applicants must have the following admission criteria by the time of application: Admission to Polk State College as a degree-seeking student, with all required admission documents received by the Registrar s Office. Minimum cumulative GPA of 2.0 upon application. Completion of college preparatory courses. Completion of prerequisite courses with a C or higher, including: o o o BSC 2085C Human Anatomy and Physiology I PSY 2012 General Psychology ENC 1101 College Composition I Completion of 20 hours of observation of occupational therapy services. Hours must be documented on the OTA Program Observation Hours Form. 7. Qualified candidates who are not admitted into the program will have to apply for the next year and submit a new application form during the designated admission window. 5

6 Page 6 APPLICATION CHECKLIST The following are minimum requirements or necessary steps for consideration for admission to your selected program. Complete each step/requirement and certify by initialing on this form that the step/requirement is met or is being pursued. Please, submit this form with your completed application to the program director. Admission as a credit student to Polk State College. High School transcripts or GED are on file with the Registrar (scores required for out of state GED). Not required if student has earned 12 or more academic college credit hours with a grade of "C" or better. College transcripts are on file with the Registrar. A copy of the transcripts is required at the time of application. Overall cumulative credit grade point average (GPA) is 2.0 or higher at the time of application (GPA of 2.0 or higher must be maintained). All prep courses completed. All prerequisite course requirements (see previous page) completed with a grade of C or better Observation hours completed. Student's signature: Date: PROGRAM DIRECTOR: I have reviewed this application and determined that it is Complete and accurate Incomplete or inaccurate Comments: Program Director s Signature: Date: Occupational Therapy Assistant Opportunities for Transformation and Autonomy 6