Evidence In Motion Education & Training Programs Manual Therapy Certification Application

Transcription

1 Evidence In Motion Education & Training Programs Manual Therapy Certification Application APPLICANT INFORMATION Date of Application: Last Name: First: Middle: Prior Names Used (Maiden Name): Professional Credentials: Date of Birth: Cohorts (circle preferred start date): Winter (January) or Summer (July) Weekend Intensive Locations (host site): Please note that your final assignment of weekend intensive location will be based upon preferences indicated as well as site and space availability. Please select your first three choices in order by listing a 1, 2, or 3 beside three of the locations below. You will be notified of your weekend intensive location in your acceptance letter. Upon payment for each management course, you will be automatically enrolled the associated weekend intensive location assigned in your acceptance letter. US Locations: Arlington, Virginia (Body Dynamics) Atlanta, Georgia (Benchmark Physical Therapy) Austin, Texas (Texas Physical Therapy Specialists) Bakersfield, California (Terrio Therapy-Fitness) Baton Rouge, Louisiana (Baton Rouge Physical Therapy)* Boise, Idaho (St. Luke s/elks Rehab) Chicago, Illinois (AthletiCo) Chicago, Illinois (ATI Physical Therapy) Evansville, Indiana (ProRehab)* Green Bay, Wisconsin (Bellin Physical Therapy) Indianapolis, Indiana (St. Vincent) Newark, Delaware (ATI/PRO Physical Therapy) rman, Oklahoma (Physical Therapy Central) Minneapolis, Minnesota (OSI Physical Therapy) Roseville, California (Sutter Health) Tacoma, Washington (Apple Physical Therapy) *t all Weekend Intensives will be held at this site. If you haven t already done so, please establish a MyEIM account (free) at:. If you already have a MyEIM account, please make sure your information is current. CONTACT INFORMATION (PLEASE DO NOT ENTER P.O BOX #. PHYSICAL ADDRESS NECESSRY FOR PROGRAM MATERIAL SHIPMENTS) Student preferred Address: Secondary Address: Preferred Phone Number: Secondary Phone Number Home Address: (Please indicate if St, Ave, Rd, etc.) City: State: Zip Code:

2 EMPLOYMENT INFORMATION Are you employed by one of the EIM Network Partners listed on page 1 (Weekend Intensive Locations)? Yes Name of Company: Work Address: Phone Number: Address: City: State: Zip Code: Which of the following best describes your current primary position? Academic administrator or director of PT education program Academic Faculty Member Consultant Partner in PT practice or business Researcher Sole owner of PT practice or business Staff PT Supervisor/Director of PT practice Other Please estimate the number of hours per week you currently spend in clinical practice providing physical therapy services for patients. (te: Include time spent in administrative aspects of providing patient care such as scheduling, coding, documentation, etc. as time spent in clinical practice.) 0-10 hours/week hours/week hours/week hours/week How many years have you been active in clinical practice? 40+ hours/week ACADEMIC BACKGROUND What degrees were you awarded upon completion of your professional (i.e. entry to practice) physiotherapy education? Baccalaureate Master s (MPT, MS, etc.) DPT Name and Location of Institution: Year of Graduation: What is your highest earned PT related degree? Baccalaureate Post-Baccalaureate Certificate Entry Level Master s (i.e. MPT, MS) Entry Level Doctorate (i.e. DPT,) Post Professional Clinical Doctorate (i.e. DHSc, DSc) Other Name & Location of Institution: Year of Graduation: Please list any previous Manual Therapy Certification courses (from EIM or other provider) that you have completed: Program Name(s): s completed: Year Completed Please list physical therapy licensure information (must provide current copy of PT license): State: License # : Expiration: CPR Certification (must provide proof of certification): Date: Expiration:

3 Please list any ABPTS board certifications you hold: Practice Specialty: Certification # Expiration Clinical Electro-physiology Geriatrics Neurological Orthopaedics Pediatrics Sports Women s Health PROFESSIONAL MEMBERSHIPS Do you have a current APTA Membership? Yes Member number : What sections do you belong to? Acute Care Aquatic PT Cardiovascular & Pulmonary Clinical Electro-physiology Education Federal PT Geriatric Hand Rehabilitation Health Policy and Administration Home Health Neurology Orthopaedic Pediatric Private Practice Research Sports PT Women s Health APPLICANTS TRAINED OUTSIDE OF THE UNITED STATES 1. Is the English language your: Native/first language Language used in your physical therapy / physiotherapy education Primary language for your daily professional / clinical practice ne of the above. If English is not your First/Native language, what is your primary language? 2. If English is not the applicants native/first language, he/she must meet the following language proficiency requirement: TOEFL (Test of English as a Foreign Language) Internet-based: Minimum score of 82 on the TOEFL. TOEFL Computer-based: Minimum score of 213. Paper-based: Minimum scores of 550. te: Our TOEFL code is 7315, please place this on your application so that we receive your scores. The TOEFL is administered by TOEFL/TSE Services, PO Box 6151, Princeton, NJ, , USA (609) Information is available on the Internet at BILLING INFORMATION Please choose your preferred method of billing for your Program; Student-Pay as you go through Program (students will NOT be enrolled in coursework until payment is received for each course. te: It is the student s responsibility to call EIM office to make payment.) Self-student billed/invoiced for Program (students will be auto enrolled in coursework) -An initial tuition payment (coordinated with Finance Office) is due within the first 30 days of the start of the program, with remaining balance due in four equal installments based on timeframe of course work. Please coordinate with Finance Office at [email protected]. Employer Billed-invoiced for coursework (students will be auto enrolled in coursework) -Payment schedule is coordinated with Finance Office at [email protected]. Billing information for responsible party Please note all payments must be made in US dollars Name: address(all invoices will be sent electronically): Discount Code:

4 REQUIRED ITEMS TO / MAIL TO EVIDENCE IN MOTION: Please check to verify all submitted Please fill out the application (ALL Applicants) electronically (i.e. MS Word) and save by using your last name, a space, and then first name. If you really want to impress, then save or print these electronically as a pdf file. Please the completed application forms together to [email protected]. An alternate option is to mail a hard-copy to: Evidence in Motion Bell rth Drive, Suite 2B Schertz, TX Attn: Application Submissions Electronic or hard copy of your current and valid Physical Therapy License(s) Electronic or hard copy of your CPR certificate Please check here to verify your TOEFL submission with code 7315 (Applicants trained outside of the US Only) $100 US Application fee (ALL Applicants) *** Please call the San Antonio office at to make all payments How did you hear about EIM s Manual Therapy Certification? STATEMENT OF EXPECTATIONS The EIM Manual Therapy Certification includes a combination of distance-based and live on-site intensive course components. This means that applicants should be technically proficient in basic internet use as well as able to travel to the on-site intensive course events. By checking the box below, you acknowledge that you have read this statement, understand its implications, and agree to the aforementioned conditions. I agree to the above statement: Yes Signature: Date: Verification sent upon successful completion of application and payment The registrar will contact you to confirm receipt of your application and application fee ($100.00, nonrefundable). Acceptance letters will be sent via after review and verification of all application requirements. Contact us at [email protected] if you have questions specifically about our Manual Therapy Certification program. Thank you for applying. We look forward to the possibility of having you join our programs. Sincerely, The Evidence in Motion Team

5 Payment Information A) Program Fees (per participant please note that prices are subject to change). Please refer to the EIM Website! for most current pricing. All prices listed here are in US dollars, and all payments should be in US dollars. Manual Therapy Certification (MTC) $ 7,150 US (plus $100 application fee & $550 materials fee) *Fees listed do not include travel related expenses for weekend intensives. B) Manual Therapy Certification Waiver/Credit Applicants who have completed other manipulative therapy certification coursework and/or the Evidence In Motion Trigger Point Dry Needling/Instrumented Soft Tissue Mobilization may be eligible for course waiver. Please contact EIM if you feel you qualify for such a waiver/constructive credit. Please note regardless of waiver, every student must take at least three of the four Management s (EIM 102, EIM 103, EIM 104, EIM 105) as a component of their MTC program. Online and hybrid courses (multi-week online didactics with an onsite weekend intensive) taken through EIM within the prior 36 months can be credited toward this MTC program if requested. te that this does not apply to standard weekend continuing education coursework. C) Manual Therapy Certification Payment Terms 1. The application fee is due upon submission of the application. 2. The materials fee ($550) is due upon receipt of acceptance letter (prior to first management course). 3. Participants may choose to register and pay for each course on a course-by-course basis. It is the responsibility of the student to contact the EIM office ( ) prior to each course to make payment (Please note: student will NOT be enrolled in coursework until payment is made). 4. Participants may choose to enroll in a tuition-based payment program. An initial tuition payment of $1,150 is due within the first 30 days of the start of the program with the remainder of the tuition balance due in four equal installments based on duration of your Program. Please contact EIM s billing department ( or [email protected]) if you would like to take advantage of this option. 5. Payment may be made via cash, check, credit card, or money order. For your convenience EIM can set up automatic payments via credit card. Please contact EIM s billing department ( or [email protected]) if you would like to take advantage of this option. 6. EIM is happy to accommodate direct billing to Sponsoring Organizations (e.g. employers) where applicable. Please contact EIM s billing department at [email protected] to facilitate this request. 7. Please note that EIM reserves the right to provide individual student grades and performance detail to each student s corresponding Sponsoring Organization if requested. 8. A late fee of $100 will be assessed by EIM if payment is made after the due date. 9. Failure to meet payment terms may result in suspension of academic activity.

6 D) Manual Therapy Certification Policy 1. EIM recognizes that conditions can occur that may necessitate a withdrawal from the Program. 2. The application fee and materials are non-refundable. 3. The programming fee is partially refundable prior to 15 th day from acceptance letter date or fully refundable within 48 hours of acceptance letter date. 4. A refund of a portion of the individual course tuition payments made for individuals who must withdraw from the Program will be provided as follows: Week of Program Length of 2 Week 4 Week 6 Week 8 Week Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 50% 75% 90% 25% 50% 75% 25% 50% 25%