OHLONE COLLEGE APPLICATION FOR ADMISSION PHYSICAL THERAPIST ASSISTANT PROGRAM

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1 OHLONE COLLEGE APPLICATION F ADMISSION PHYSICAL THERAPIST ASSISTANT PROGRAM When completed, return this form with in-progress grades and one (1) set of Official Transcripts from all colleges attended, to: OHLONE COLLEGE Health Sciences Division Room 1324 Attn: PTA Program Cherry St. Newark, CA (510) Ohlone College s PTA Program is accredited by the Commission on Accreditation in Physical Therapy Education. Date: Application Name: Ohlone College Id # Previous or Maiden Name(s): Address: Phone: Street address (required) City county state zip code What has led you to conclude that you want to enter this field of study _ Related work experience, if any: (Verification in the form of letter, signed by your supervisor, is required) Dates Job Description Employer/Supervisor Phone # Education High School (last attended): Graduation Date: Address:

2 College: Dates of Attendance to Degree Have you ever been accepted and/or attended any other Physical Therapy, Physical Therapist Assistant, or Health Science program before? Yes ; No If yes, answer questions below: Name of College/Program Date(s): Reason for leaving: Will you be able to provide your own transportation and/or assume financial responsibility for travel to clinical assignments? Yes ; No If not, please explain below: Check the following courses that have been completed prior to, or are in progress at the time of this application: Anatomy Physiology PTA 101 (Introduction to Physical Therapy) If accepted into this program, I will abide by all of the program policies and procedures. I certify that the statements and information on this application are true and complete to the best of my knowledge. Signed: Date:

3 NAME: OHLONE COLLEGE ID: OHLONE COLLEGE APPLICATION TO THE PHYSICAL THERAPIST ASSISTANT PROGRAM F APPLICANT USE ADMISSIONS & RECDS USE ONLY REQUIREMENTS: 1. Eligibility for Eng. 101A Asset Test Completion of Eng. 151B with C or above Completion of equivalent course with C or above. (Check one) 2. Reading comprehension Asset Test Completion of Eng. 163 with C or above (Check one) Not required for earned BS/BA 3. Anatomy and Physiology Completion of BIO. 103A with a grade of C Or above within past 5 years Completion of equivalent course with grade of C or above within past 5 years (Check one) AND Completion or in progress BIO. 103B with grade C or above within past 5 years Completion or in progress equivalent course with grade of C or above within past 5 years. Asset Score Grade: Eng. 151B Equiv. or high level course Asset Score of 19 or above Grade: Eng. 163 BS/BA-U.S. Accredited Grade for BIO 103A Within 5 years Grade for equiv. Course Within 5 years AND Grade for BIO. 103B Within past 5 years Grade for equivalent course Within past 5 years 4. GPA of 2.50 or above from an accredited institution of higher learning in the U.S. Cumulative GPA 5. PTA 101 In progress grade of C equivalent course Grade for equiv. course need Date: Applicant Signature: Please note that it is the applicant s responsibility to assure that all test scores, transcripts from other colleges, in progress grades, and other documentation be in the Health Sciences Division Office no later than 5:00 p.m. on the last date of the application period (April 1-15). Applicants will be notified of their status via , no later than June 30 th. All applicants who verify completion of requirements 1 to 5 will be considered eligible for admission to the PTA program and will be selected by randomized lottery. All potential applicants must complete an online school application to Ohlone College in order to obtain their student ID number. Since a three year validation study is being conducted to determine the relationship between previous work experience in the field and success in the program, a proportion of each class will include identified students with and without work experience.

4 IN PROGRESS GRADE REPT ATTACH TO PTA PROGRAM APPLICATION COURSE NUMBER & TITLE: UNITS: NAME OF COLLEGE: IN-PROGRESS GRADE: ANTICIPATED FINAL GRADE: INSTRUCT SIGNATURE: DATE: IN PROGRESS GRADE REPT ATTACH TO PTA PROGRAM APPLICATION COURSE NUMBER & TITLE: UNITS: NAME OF COLLEGE: IN-PROGRESS GRADE: ANTICIPATED FINAL GRADE: INSTRUCT SIGNATURE: DATE:

5 PROSPECTIVE STUDENT DATA SURVEY The California State Chancellor is asking us to gather data on all students who submit an application to the physical therapist assistant program. Please assist us by completing the information as listed. Your responses will remain confidential and untraceable, as the sheet will be separated from the application. Thank you for your assistance in the matter. 1. Birthplace a. California b. Another state in the United States c. A country other than the United States 2. Age group a. 18 to 25 years of age b. 26 to 35 years of age c. 36 to 45 years of age d. 46 to 55 years of age e. 56 years of age or over 3. Sex a. Female b. Male 4. Ethnicity a. African-American b. Asian c. Caucasian/White d. East Indian e. Filipino f. Latino/Latina g. Middle Eastern h. Native American or Alaskan Native i. Pacific Islander j. Other: please specify: 5. Marital Status a. Single/never married b. Married c. Separated/Divorced d. Widowed 6. Are you attending school on a VISA? No: YES: type: Are you in the US on a VISA? No: YES: type: Last updated & revised: March 5, 2013

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