PHYSICAL THERAPIST ASSISTING

108 N. 40th Street Phenix, AZ 85034 (602) 286-8000 www.gatewaycc.edu INFORMATION & APPLICATION PACKET 2015 2016 PHYSICAL THERAPIST ASSISTING Assciate in Applied Science Degree in Physical Therapist Assisting

108 N. 40th Street Phenix, AZ 85034 (602) 286-8000 www.gatewaycc.edu

108 N. 40th Street Phenix, AZ 85034 (602) 286-8000 www.gatewaycc.edu Physical Therapist Assisting Dear Prspective Student: Thank yu fr yur interest in the Physical Therapist Assisting Prgram at GateWay Cmmunity Cllege. Please review the enclsed Infrmatin and Applicatin Packet. If yu decide t apply fr admissin int the prgram, cmplete all the required steps nted n the INFORMATION SHEET and APPLICATION PROCESS pages f the packet. Please nte the applicatin perids fr the hybrid weekend prgram and the day prgram. Applicatins t the prgram will nly be accepted during the designated applicatin perids. Please access ne f the fllwing resurces r the prgram website if yu have additinal questins abut the prgram: Website: http://www.gatewaycc.edu Cllege Advising: 602-286-8600; advisr@gatewaycc.edu Carlynn Delgad; 602-286-8183; delgad@gatewaycc.edu Luciella Granillp; 602-286-8185; luciella.granill@gatewaycc.edu Peter Zawicki, PT, MS Prgram Directr / 602.286.8476 / E-mail: zawicki@gatewaycc.edu Please nte that the curriculum and prerequisites fr the prgram will be revised peridically. It is the applicant s respnsibility t remain aware f changes that ccur. I wish yu success in yur educatinal and career pursuits. Sincerely, Peter Zawicki, PT, MS Directr - Physical Therapist Assistant Prgram A Maricpa Cmmunity Cllege learn mre. live better.

108 N. 40th Street Phenix, AZ 85034 (602) 286-8000 www.gatewaycc.edu TABLE OF CONTENTS Applicatin Prcess... 5 Frequently Asked Questins Abut Careers in Physical Therapy... 5 Frequently Asked Questins Abut the Prgram... 7 Immunizatins, Testing, and Backgrund Requirements... 10 Estimated Prgram Csts... 11 Prerequisites fr Physical Therapist Assisting... 12 Assciated f Applied Science Degree... 12 Assciate in Applied Science Degree - Day Prgram... 13 Assciate in Applied Science Degree Hybrid Weekend Prgram... 14 Legal Prcedures... 15 Cnfidentiality Statement... 15 Accreditatin(s)... 15 Plicies, Rules, Requirements, and Regulatins Cmpliance... 16 Cllege Cmmunicatin... 16 Student Services... 17 Essential Functins... 17 Vlunteer / Wrk / Observatin Hurs... 18 Vlunteer / Wrk / Observatin Hurs Verificatin & Assessment Frm... 18 Vlunteer / Wrk / Observatin Hurs - Verificatin & Assessment Frm... 19 Vlunteer / Wrk / Observatin Hurs - Verificatin & Assessment Frm (cnt'd)... 20 Vlunteer / Wrk / Observatin Hurs - Verificatin & Assessment Frm (cnt'd)... 21 Prgram Applicatin Physical Therapist Assistant... 23 Physical Therapist Assisting Admissin Applicatin Checklist/Advisr Review... 25 MCCCD Summary f Criminal Backgrund Check Requirements... 27 MCCCD Acknwledgement f Criminal Backgrund Check Requirements... 29 Physical Therapist Assisting 4 Octber 15-1

APPLICATION PROCESS STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 STEP 6 See a Cllege Advisr r visit www.gatewaycc.edu a. Receive a prgram infrmatin and applicatin packet Read the entire packet carefully a. Cntact a cllege advisr t discuss questins Cmplete the Student Infrmatin Frm t the Cllege a. Obtain frm at the Admissins and Recrds ffice r at: http://enrll.gatewaycc.edu/enrllment/hwtenrll/default.htm b. Submit frm t Admissins and Recrds Transcripts Request fficial transcripts frm clleges/universities t be sent t the Admissins and Recrds Office, GWCC, 108 N. 40th St., Phenix, AZ 85034. a. Official transcripts must be sent frm institutin t institutin, allw 2-4 weeks fr receipt. Please request the institutin t include current name and student ID number used at GateWay Cmmunity Cllege. Cmplete pre-requisites (see page 12). See page 18 regarding the required vlunteer/wrk experience. Submit pages 19-21 t the Admissins and Recrds upn cmpletin f the experience. Submit the COMPLETED applicatin (page 23) t the Admissins and Recrds Department. See the Selective Annual Admissins Prcess n page 9 fr the applicatin perids fr the hybrid weekend prgram and the day prgram. A cmpleted applicatin packet cnsists f: 1. Official cllege/university transcripts received by GWCC Admissins and Recrds. 2. Cmpleted Student Infrmatin Frm submitted t Admissins and Recrds 3. Dcumentatin f cmpletin f ENG101 and BIO160/BIO201 with a 3.0 GPA and a minimum grade f B in each curse. 4. Cmpleted verificatin f vlunteer/wrk/bservatin/ f 40 hrs. (SEE PAGES 19-21) 5. Cmpleted applicatin t prgram (SEE PAGE 23) FREQUENTLY ASKED QUESTIONS ABOUT CAREERS IN PHYSICAL THERAPY What is Physical Therapy? Physical therapy (PT) is the art and science f prviding care t patients suffering frm injury r disease which has resulted in a lss f mtin in the jints f the bdy, a lss f strength in muscles, increased pain, an inability t walk nrmally, as well any f several ther examples f lsses f physical functin. Thrugh physical therapy, patients are helped t regain the ability t functin at their highest pssible level. Patients may include infants, children, adults, and the elderly. Wh prvides Physical Therapy? Physical therapists (PTs) assess patients, determine what treatment is necessary, and perfrm skilled treatments. Physical therapists assistants (PTAs) are supervised by the physical therapist. They help the physical therapist by perfrming selected treatment activities with patients. I really want t becme a physical therapist d I need t becme a physical therapist assistant first? Individuals interested in becming physical therapists d nt need t cmplete educatin as a PTA t becme a PT. Physical Therapist Assisting 5 Octber 15-1

What Educatin is Necessary? Individuals interested in becming physical therapists cmplete a bachelr s degree prir t making applicatin t enter an educatinal prgram. Prgrams fr the educatin f physical therapists are at the dctral level and generally take three years t cmplete. Physical therapist assistants attend cmmunity r technical clleges that ffer an assciate s degree. Prgrams can be cmpleted in 3-5 semesters. Where d PTs and PTAs wrk? PTs and PTAs are emplyed in hspitals, skilled nursing facilities, schls, hme health and utpatient practice settings. Hw much mney d PTs and PTAs make? Infrmatin abut wages and salaries fr physical therapists can be fund at http://www.bls.gv/es/current/es291123.htm Infrmatin abut wages and salaries fr physical therapist assistants can be fund at http://www.bls.gv/es/current/es312021.htm What is the current jb market fr PTAs? The United States Department f Labr/Bureau f Labr Statistics states, Emplyment f physical therapist assistants and aides is prjected t grw 41 percent frm 2012 t 2022, much faster than the average fr all ccupatins. Demand fr physical therapy services is expected t increase in respnse t the healthcare needs f an lder ppulatin and grwing rates f chrnic cnditins such as diabetes and besity. Graduates f the PTA Prgram at GateWay Cmmunity Cllege are currently in high demand. Why shuld I cnsider a career in physical therapy? A career in physical therapy is very rewarding. Each day physical therapists and physical therapist assistants wrk clsely with their patients t help them recver frm injuries r illnesses that have temprarily r permanently changed their lives. PTs and PTAs are imprtant members f the rehabilitatin team. Helping peple t prgress back twards ptimal health is a wnderful experience. PTs and PTAs wrk in hspitals, rehabilitatin centers, hme health, schls, skilled nursing facilities, utpatient clinics and sprts medicine centers. Wrk hurs are generally during the daytime, Mnday thrugh Friday. Weekend wrk is generally available r required at hspitals and skilled nursing facilities. PTs and PTAs are men and wmen wh enjy challenging wrk, cmmunicating with peple, and wrking in a team t assist patients t achieve their fullest rehabilitatin ptential. D I need t pass an examinatin t be a PT r PTA? T hld the title f physical therapist r physical therapist assistant in Arizna an individual must pass the Natinal Physical Therapy Examinatin (NPTE) fr the respective level f educatin and training. The examinatin is administered by the Federatin f State Bards f Physical Therapy (FSBPT). Csts assciated with the applying fr licensure/certificatin and taking the examinatin are apprximately $600. If I have a criminal recrd, will that prhibit me frm being successful in this career? Clinical agreements with the healthcare facilities require that students pssess a Fingerprint Clearance Card issued by the Arizna Department f Public Safety. Additinally, a student must nt be listed n the Federal Gvernment s Office f the Inspectr General s Exclusin List. Students that are unable t btain either f these clearances will be prhibited frm attending all healthcare educatin prgrams at GateWay Cmmunity Cllege. Physical Therapist Assisting 6 Octber 15-1

FREQUENTLY ASKED QUESTIONS ABOUT THE PROGRAM Hw many students are admitted t the prgram? A new class f 24 students is admitted each August t the traditinal day prgram. The weekend/hybrid educatin prgram admits a new class f 20 students in May f each year. The number f students admitted may change depending n emplyment market cnditins and the availability f clinical training sites. What d I need t d t apply t the prgram? It is recmmended that interested students cntact a cllege advisr t discuss the prgram (602-286- 8600 r advisr@gatewaycc.edu). PTA faculty are als frequently available fr cnsultatin. Fllwing these initial meeting, students shuld then wrk t cmplete the fllwing: a) BIO160 (r BIO201) b) ENG101 c) 40 hurs f wrk/vlunteer experience in physical therapy with a minimum f 20 hurs in an inpatient (hspital, skilled nursing care, etc.) facility. Interested applicants are encuraged t allw adequate time t cmplete this requirement. It may take sme time t lcate a site, establish a schedule, and cmplete the required hurs. The abve requirements MUST be cmpleted prir t submitting an applicatin t the prgram. A grade pint average f 3.0 fr BIO160/201 and ENG101 must be achieved t be admitted int the prgram with a minimum grade f B in each curse. What happens t my applicatin if I am nt accepted int the prgram? The prspective applicant will need t reapply fr admissin int the prgram during the next applicatin cycle. Hw lng des it take t cmplete the prgram? The day prgram can be cmpleted in five semesters. Students admitted t the day prgram in August 2016 will graduate in May 2018, if all lecture, labratry, and clinical curses are cmpleted satisfactrily. Students admitted t the weekend/hybrid educatin prgram in May 2017 will graduate in September 2018, if all lecture, labratry, and clinical curses are cmpleted satisfactrily. Many students take a year prir t actually beginning prgram curses t cmplete prgram prerequisites and general educatin curses that are required fr the Assciate in Applied Science (AAS) degree. Are the PTA Prgram curses transferable t clleges r universities if I decide t pursue a bachelr s degree? Certain bachelr s degree prgrams will accept up t 90 credits frm the prgram. Cntact cllege advising (602-286-8600) fr further infrmatin. Als, see www.nau.edu/extended fr infrmatin abut the Bachelr f Science in Health Sciences Physical Therapist Assisting. When are the classes scheduled? Fr the day prgram, lecture and lab classes may be scheduled Mnday thrugh Friday. Classes may begin as early as 7:00 a.m. and end as late as 4:00 p.m. Depending n the semester, students may be in class fr 3-6 hurs per day, 3-4 days per week. Fr the weekend/hybrid educatin prgram lecture curses will be nline with peridic n campus testing. Lab classes will be scheduled Friday (1:00-7:00 PM, mrnings may be used fr testing, review, etc.) and Saturday and Sunday, 7:30 a.m. t 5:00 p.m., n alternating weekends. All f the lab classes are held n site at GateWay Cmmunity Cllege. There are apprximately 20 weekends f required n campus attendance fr lab classes in the hybrid prgram. Clinical practicum classes (PTA206, 280, and 290) fr bth the traditinal day prgram and the hybrid weekend prgrams are Mnday thrugh Friday fr eight (8) hurs each day fr six cnsecutive weeks. Extended hurs and weekends are ccasinally necessary during clinical experiences. These classes require attendance at clinical facilities that include hspitals, extended care facilities, and utpatient practices. Physical Therapist Assisting 7 Octber 15-1

What facilities d I cntact t cmplete my vlunteer/wrk experience? Applicants are encuraged t cntact lcal hspitals, nursing hmes, and private physical therapy ffices t arrange fr vlunteer experience. The prgram requires that 40 hurs f vlunteer r wrk experience must be cmpleted prir t entering the prgram. A minimum f 20 hurs must cmpleted at an inpatient (hspital, skilled nursing care, etc.) facility. Fr vlunteer experiences, this requirement will ften invlve bserving physical therapy practice withut any direct patient interactin. Receiving physical therapy fr a persnal injury r medical cnditin will nt be cnsidered as part f the vlunteer experience requirement. Can I wrk and g t schl? Fr the day and hybrid/weekend educatin prgrams, applicants are cautined that the PTA Prgram is a rigrus curse f study. The prgram faculty recmmends that wrk hurs be kept t a minimum. Each student must make an individual decisin abut the number f wrk hurs that he/she can accept while cntinuing t make acceptable academic prgress in the prgram. Is financial aid available? Financial assistance is available t eligible students in the frm f grants, schlarships, emplyment, r lans. Students may receive aid frm ne funding surce r aid may be ffered in a package frm multiple surces. Cntact the Financial Aid ffice at 602.286.8300/finaid@gatewaycc.edu fr additinal infrmatin r visit their web site at http://www.gatewaycc.edu/financial-aid Des the weekend/hybrid educatin prgram have special requirements? Students in the weekend/hybrid educatin prgram will need regular access t a cmputer with internet capabilities (high speed service is preferred). Students must be cmputer literate and must be able t access dcuments that are presented in Micrsft Wrd and PwerPint. Windws Media Player, r similar sftware, is als required. Students will be traveling t GateWay n alternating weekends and thus reliable mtr vehicle transprtatin is essential. Students in this educatin prgram wh travel frm a distance will need t make their wn ldging arrangements fr the weekend lab classes. Every effrt will be made place students in their lcal cmmunities fr clinical educatin rtatins. In the event that this is nt pssible students may be required t drive many miles t the nearest available clinical site. Once I start the prgram, can I transfer frm the hybrid prgram t the day prgram r frm the day prgram t the hybrid prgram? Requests t transfer frm ne prgram t the ther will be cnsidered n a case-by-case basis. Transfer may nt be pssible due t a variety f reasns. Where can I get mre infrmatin? Website: http://www.gatewaycc.edu Cllege Advising: 602-286-8600; advisr@gatewaycc.edu Carlynn Delgad; 602-286-8183; delgad@gatewaycc.edu Luciella Granillp; 602-286-8185; luciella.granill@gatewaycc.edu Peter Zawicki, PT, MS Prgram Directr / 602.286.8476 / E-mail: zawicki@gatewaycc.edu Physical Therapist Assisting 8 Octber 15-1

GateWay Cmmunity Cllege Physical Therapist Assistant Prgram Selective Annual Admissin Prcess Applicants fr the Physical Therapist Assistant Prgram at GateWay Cmmunity Cllege will be ranked n a pint based system. The criteria listed belw will be used in the ranking prcess. Applicants fr the prgram will be selected based n the pints earned. Applicatins fr the hybrid weekend prgram will be accepted frm July 1 thrugh September 30. Applicants will be ntified f their status by Nvember 15. Late applicatins may be cnsidered fr admissin if additinal spaces remain in the prgram after the initial acceptance prcess has been cmpleted. The hybrid weekend prgram starts in mid-may. Applicatins fr the day prgram will be accepted frm December 1 thrugh February 28. Applicants will be ntified f their status by May 1. Late applicatins may be cnsidered fr admissin if additinal spaces remain in the prgram after the initial acceptance prcess is cmpleted. The traditinal day prgram starts in mid-august. Any applicant that is nt accepted but remains interested in the prgram will be required t reapply fr admissin fr the next prgram admissin. 1. Grade in BIO160 r BIO201 must earn 2 pints in this categry and credit must have been earned within the past 10 years a. A = 4 pints b. B = 2 pints c. C, D r F = applicatin will nt be cnsidered 2. Grade in ENG101 must earn 1 pint in this categry a. A = 2 pints b. B = 1 pints c. C, D r F = applicatin will nt be cnsidered 3. Wrk r vlunteer experience in physical therapy submit required verificatin frm(s) must earn 1 pint frm this categry. a. Wrk experience as a physical therapy aide/technician - 2080+ hurs with a minimum f 20 hurs f wrk/vlunteer experience in an inpatient (hspital, skilled nursing facility, and r rehabilitatin hspital) facility required = 3 pints b. Wrk experience as a physical therapy aide/technician 1040 t 2079 hurs with a minimum f 20 hurs f wrk/vlunteer experience in an inpatient facility required = 2 pints c. 40 r mre hurs f vlunteer experience in a physical therapy practice OR 40-1039 hurs f wrk experience as a physical therapy aide/technician = 1 pint; minimum f 20 hurs in an inpatient facility required 4. Cmpletin f general educatin requirements (ENG102, MAT, COM, HCC130, HCC146, PSY101, Humanities, CRE) with a minimum grade f C in each curse. a. 8 curses cmpleted = 3 pints b. 4-7 curses cmpleted = 2 pints c. 1-3 curses cmpleted = 1 pint 5. Wrk/vlunteer recmmendatin rating a. Cumulative average f 9.5 t10 = 3 pints b. Cumulative average f 8.5 t 9.49 = 2 pints c. Cumulative average f 7.5 t 8.49 = 1 pint d. Cumulative average f 0 t 7.49 = 0 pints 6. AA degree r higher 1 pint 7. Medical credential with AA degree r higher in the field f study 1 pint 8. Essay Questin 0-3 pints based n a grading rubric. a. A maximum f 48 students will be invited t campus t cmplete an essay n March 26, 2016 as part f the admissin prcess t the traditinal day prgram t begin in August 2016. A maximum f 40 students will be invited t campus t cmplete an essay n Octber 22, 20165as part f the admissin prcess t the hybrid weekend prgram t begin in May 2017. Applicants with the highest cumulative pint ttal frm number 1 thrugh 7 abve will be invited t cmplete the essay. 9. PTA Prgram admissins test required after admissin. Physical Therapist Assisting 9 Octber 15-1

IMMUNIZATIONS, TESTING, AND BACKGROUND REQUIREMENTS IMMUNIZATION AND TB TESTING REQUIREMENTS Please review the health and safety packet available at http://www.gatewaycc.edu/sites/default/files/imce/images/infpacket_alliedhealthprgrams.pdf The health and safety requirements are subject t change based n the requirements f ur clinical partners. The mst up t date infrmatin is lcated at the afrementined website. MCCCD BACKGROUND CHECK POLICY REQUIREMENTS Students seeking admissin t an MCCCD Allied Health r Nursing Prgram (Prgram) will be required t btain a valid Level-One Arizna Department f Public Safety Fingerprint Clearance Card (FCC Card) AND a passing scre n an MCCCD backgrund check. This plicy precludes MCCCD faculty r staff frm assigning students t a clinical experience wh cannt meet the new requirements. Please review the plicy annuncement and FAQs n the MCCCD website https://asa.maricpa.edu/departments/healthcare-educatin-at-the-maricpa-cmmunity/maricpacmmunity-clleges-dental-hygiene/healthcare-educatin-ther-student-infrmatin. Upn admissin t the prgram, students are required t present a cpy f the DPS card and apply fr the MCCCD Backgrund Check. Students bear the financial csts fr bth the MCCCD Backgrund Check and the AZ Fingerprint Clearance Card. Students will receive Infrmatin regarding the MCCCD Backgrund Check after admissin, but prir t the beginning f the prgram. Students are encuraged t apply fr the card early in the applicatin prcess. Please allw a minimum f eight weeks prcessing time fr the DPS Level-One Fingerprint Clearance card. The card is valid fr six years frm the date f issue. DRUG SCREENING Each student must g thrugh a preclinical drug screen prir t beginning the first clinical rtatin. Drug screening fr all Physical Therapist Assisting students is mandatry. The cst fr tests will be the respnsibility f the student. The urine drug screen will test fr alchlic beverages; illegal drugs, r drugs that may impair judgment while in the clinical agency. If the drug test is psitive fr the illegal drugs r undcumented prescriptin drugs, the student will nt be able t cntinue in the prgram. Readmissin is at the discretin f the cllege and the prgram. Sme clinical sites als require screening fr nictine. Students wh test psitive fr nictine are allwed t cntinue in the prgram, but may be limited t clinical agencies that d nt test fr nictine. Physical Therapist Assisting 10 Octber 15-1

ESTIMATED PROGRAM COSTS The estimated cst fr the prgram is utlined in the chart belw. The student is respnsible fr prviding transprtatin, husing, and unifrms. AAS Degree Prgram Tuitin* (53 credit hrs @ $84 a credit hr) 1... $ 4,452 Prgram Prerequisite Tuitin (9-17 credit hrs @ $84 a credit hr) 1... 756 1,428 General Educatin Tuitin (11-15 credit hrs @ $84 a credit hr) 1... 924 1,428 Registratin fees ($15 per semester)... 75 Curse / Lab Fees... 510 580 Equipment / Supplies... 83 Bks 3... 1,900 2,757 Other Prgram Csts: Health/Safety Requirements, etc. 2... 817 1,482 Ttal Estimated Csts $ 9,517 12,285 Out-f-Cunty residents pay $359* / Out-f-State residents pay $325** a credit hr 1 * Rates are set accrding t Arizna Revised Statute. Applies nly t cunties with n cmmunity clleges. ** Accrding t Arizna Revised Statute, 15-1802 F, "A persn wh is a member f an Indian tribe recgnized by the US Department f the Interir whse reservatin land lies in this state and extends int anther state and wh is a resident f the reservatin is entitled t classificatin as an in-state student." Therefre, unclassified and ut f state surcharges d nt apply t such students. Students must als plan n the expense f driving t clinical lcatins acrss the metrplitan Phenix and utlying areas. Several clinical affiliates are nt n bus rutes s ne s wn private transprtatin vehicle is necessary. 1 Tuitin and curse fees are set by the Maricpa Cunty Cmmunity Cllege District Gverning Bard and subject t change withut ntice. All ther fees are als subject t change. All tuitin and fees are the respnsibility f the student. The calculated tuitin is based n the maximum number f credits required fr the AA degree. 2 Other Prgram Csts may be less r mre than listed based n a student s individual health recrd in respect t being in cmpliance with the immunizatin and safety requirements fr the clinical experience. 3 Bk csts may change withut ntice IMPORTANT Tuitin/registratin fees are all due 35 days prir t the start date f each curse. If 34 days r less, all fees are due at the time f registratin r yu will be drpped frm yur curses and lse yur seat in the prgram fr nn-payment. Physical Therapist Assisting 11 Octber 15-1

PREREQUISITES FOR PHYSICAL THERAPIST ASSISTING Please read all pertinent infrmatin abut the Physical Therapist Assisting Prgram cntained in this infrmatin and applicatin packet. If yu have any questins, please cntact a Cllege Advisr r the Prgram Directr. 1. Submissin f a cmpleted Student Infrmatin Frm. See a cllege advisr r the Admissins and Recrds Department r access the web at: http://enrll.gatewaycc.edu/enrllment/hwtenrll/default.htm 2. 40 r mre hurs f vlunteer experience in a physical therapy practice setting with a minimum f 20 hurs frm an inpatient facility. See page 18 fr additinal infrmatin. 3. Successful cmpletin f the fllwing cllege curses: CREDITS ENG101 First Year Cmpsitin 3.0 BIO160 Intrductin t Human Anatmy and Physilgy OR BIO201 Human Anatmy & Physilgy I 4.0 TOTAL 7.0 NOTE: A minimum 3.0 cumulative G.P.A. in prerequisite curses is required t enter the prgram and a grade f B r higher is required in each curse. ASSOCIATED OF APPLIED SCIENCE DEGREE A student must fulfill the requirements fr an AAS degree (refer t the cllege catalg) t becme a Physical Therapist Assistant. It is strngly recmmended that as many General Educatin curses as pssible be cmpleted prir t beginning the prgram and during the first semester. ENG102 Cmpsitin 3.0 credits Mathematics Elective 3.0 5.0 credits Cmmunicatin Elective 3.0 credits Humanities Elective 2.0 3.0 credits CRE101/111 Critical Reading 0 3.0 credits (Waiver by assessment ffered) Ttal credits 11.0 17.0 credits The abve classes may be taken at any reginally accredited cmmunity cllege r university. Fr classes taken utside the Maricpa Cmmunity Cllege District, please cntact a cllege advisr prir t taking the curse t ensure transferability. Please see the GateWay Cmmunity Cllege Catalg fr a list f curses that satisfy requirements fr the AAS degree. Ttal Credits fr an AAS in Physical Therapist Assisting Required prgram credits 53.0 General Studies 11.0 17.0 Ttal credits 73.0 87.0 Additinal Requirements Prir t the first clinical practicum (PTA206), a student must shw prf f: Current American Heart Assciatin Health Care Prvider CPR Certificatin card Cmpleted Immunizatin and Health Declaratin Frm Current negative drug testing Fingerprint clearance card/criminal backgrund check American Heart Assciatin Health Care Prvider CPR Certificatin may be cmpleted at GateWay (RES109/HCC109). All csts fr CPR certificatin, TB testing, immunizatins, fingerprint clearance and drug testing are the respnsibility f the student. Ttal Credits f A.A.S. in Physical Therapist Assisting Prgram 76.0 80.0 credits Physical Therapist Assisting 12 Octber 15-1

ASSOCIATE IN APPLIED SCIENCE DEGREE - DAY PROGRAM PTA Prgram Pre-requisites: 7 credits 40 hurs vlunteer/bservatin/wrk experience BIO160 Intr t Human Anatmy and Physilgy I (4)OR BIO201 Human Anatmy and Physilgy I 4 credits ENG101 First Year Cmpsitin 3 credits PTA Curses First Fall (Aug- Dec) 12.5 credits PTA101 Survey f Physical Therapy - 1.5 credits PTA103 Kinesilgy 3 credits PTA104 Musculskeletal Assessment Techniques - 1.5 credits PTA205 Cmmunicatin in Physical Therapy - 1.5 credits HCC130 Fundamentals f Health Care Delivery (3 credits) OR equivalent curse educatin HCC145/146 Cmmn Medical Terminlgy fr Health Care Wrkers 2-3 credits PTA Curses First Spring (Jan-May) 12.0 credits PTA200 Patient Mbility Techniques (lecture and lab) 4 credits PTA202 Selected Physical Therapy Mdalities (lecture and lab) 5 credits PTA203 Clinical Pathlgy 3 credits PTA Curse First Summer (May-June) 4.0 credits PTA206 Clinical Practicum I 3 credits PTA207 Clinical Practicum I Seminar 1 credit PTA Curses Secnd Fall (Aug-Dec) 14.5 credits PTA 208 Rehab f Special Ppulatins (lecture and lab) 5 credits PTA 210 Orthpedic Physical Therapy (lecture and lab) 4 credits PTA 214 Electrmdalities (lecture and lab) 2.5 credits PTA 215 Wund Care Management* - 1 credit PTA 217 Clinical Neurlgy 2 credits PTA Curses Secnd Spring (Jan-May) 12.0 credits PTA230 Physical Therapy Seminar 2 credits PTA280 Clinical Practicum II 3 credits PTA281 Clinical Practicum Seminar II 1 credit PTA290 Clinical Practicum III 3 credits PTA292 Clinical Practicum Seminar III 1 credit PTA295 PTA Exam Review 2 credits General Educatin Curses** 14.0 20.0 credits ENG102 First Year Cmp. 3.0 credits PSY101 3.0 credits (fulfills Scial & Behaviral Sciences elective) Math Elective 3.0 5.0 credits Cmmunicatin Elective 3.0 credits Humanities Elective 2.0 3.0 credits Critical Reading 0 3.0 credits (May exempt thrugh examinatin) ** General Educatin curses may be taken at any Maricpa Cunty Cmmunity Cllege r reginally accredited cllege r university. If taken utside f the MCCCD system, cnsult an advisr t ensure transferability. General educatin curses must be cmpleted in rder t graduate. See the cllege catalg fr a list f curses that meet general educatin requirements. HCC curses may be taken prir t the start f the prgram. Physical Therapist Assisting 13 Octber 15-1

A SSOCIATE IN A PPLIED SCIENCE D EGREE H YBRID W EEKEND P ROGRAM *All curse dates subject t change PTA Prgram Prerequisites Credits BIO160/201 Human Anatmy and Physilgy 4.0 ENG101 Freshman Cmpsitin 3.0 40 hurs wrk experience r vlunteer/bservatin experience Blck I (May August 2017*) PTA101 Survey f Physical Therapy 1.5 PTA103 Kinesilgy 3.0 PTA203 Clinical Pathlgy 3.0 HCC130 Fundamentals in HealthCare Delivery OR equivalent curse educatin 0-3.0 HCC146 Cmmn Medical Terminlgy fr Health Care Wrkers 2.0 Blck II (August September 2017*) PTA104 Musculskeletal Assessment 1.5 PTA217 Clinical Neurlgy 2.0 Blck III (September Octber 2017*) PTA200 Patient Mbility Techniques 4.0 Blck IV (Octber December 2017*) PTA202 Selected Physical Therapy Mdalities 5.0 PTA205 Cmmunicatin in Physical Therapy 1.5 Blck VI (January February 2018*) PTA206 Clinical Practicum I 3.0 PTA207 Clinical Practicum Seminar I 1.0 Blck VII (January February 2018*) PTA208 Rehabilitatin f Special Ppulatins 5.0 Blck VIII (March 2018*) PTA210 Orthpedics 4.0 Blck IX (April May 2018*) PTA214 Electrmdalities 2.5 PTA215 Wund Care fr the Physical Therapist Assistant 1.0 PTA295 PTA Examinatin Review 2.0 Blck X (May June 2018*) PTA280 Clinical Practicum II 3.0 PTA281 Clinical Practicum Seminar II 1.0 Blck XI (July August 2018*) PTA290 Clinical Practicum III 3.0 PTA292 Clinical Practicum Seminar III 1.0 PTA230 PT Seminar 2.0 Physical Therapist Assisting 14 Octber 15-1

Additinal required curses: ENG102 First Year Cmpsitin 3.0 PSY101 Scial and Behaviral Sciences 3.0 MAT+ See cllege catalg fr a list f curses that meet this requirement. 3.0 +COM++ See cllege catalg fr a list f curses that meet this requirement. 3.0 HUM See cllege catalg fr a list f curses that meet this requirement. 2.0 3.0 CRE101+ See cllege catalg fr a list f curses that meet this requirement. CRE111+ 0 3.0 LEGAL PROCEDURES Fingerprinting: The prgram requires fingerprinting and backgrund checks prir t admissin t the prgram. Students are respnsible fr any csts assciated with fingerprinting. T btain a DPS Level I Finger Print Clearance Card call 602.223.2279 and request a finger print clearance card packet r yu can visit them in persn at 2102 W. Encant Blvd. in Phenix and pick up the packet. http://www.azdps.gv/reprts/fingerprint/faq/default.asp Felnies: Cmmissin f a felny must be disclsed t the Arizna Bard f Physical Therapy upn applicatin fr Physical Therapist Assistant Certificatin. It is the decisin f the Bard whether r nt t grant certificatin after cmmissin f a felny. Fr further infrmatin cntact: Arizna State Bard f Physical Therapy at 602.274.0236 r visit their web site at www.ptbard.state.az.us CONFIDENTIALITY STATEMENT Students enrlled in the prgram will have learning experiences in a health care setting where they will have access t cnfidential infrmatin. Prir t beginning any clinical studies the students will be required t sign an agreement t adhere t the requirements f thse clinical sites and applicable laws, including the Health Infrmatin Prtability and Accuntability Act f 1996 (HIPAA). ACCREDITATION(S) GateWay Cmmunity Cllege is a Maricpa Cunty Cmmunity Cllege and is accredited by the Higher Learning Cmmissin, a Cmmissin f the Nrth Central Assciatin f Clleges and Schls (30 Nrth LaSalle St, Suite 2400, Chicag, IL 60602-2504, Tel# 800.621.7440). Curses are apprved by the Scial Security Administratin fr Veterans Training. This schl is authrized under federal law t enrll nnimmigrant alien students. The Physical Therapist Assistant Prgram at GateWay Cmmunity Cllege is accredited by the Cmmissin n Accreditatin in Physical Therapy Educatin (CAPTE), 1111 N Fairfax Street, Alexandria, VA 22314; phne: 703-706-3245; email: accreditatin@apta.rg; website: http://www.captenline.rg. Physical Therapist Assisting 15 Octber 15-1

POLICIES, RULES, REQUIREMENTS, AND REGULATIONS COMPLIANCE Plicies, curses, prgrams, fees, and requirements may be suspended, deleted, restricted, supplemented, r changed thrugh actin f the Gverning Bard f the Maricpa Cmmunity Clleges. The Maricpa Cmmunity Clleges reserves the right t change, withut ntice, any materials, infrmatin, curriculum, requirements, and regulatins. Admissin r graduatin frm any Allied Health prgram at GateWay Cmmunity Cllege des nt guarantee the student s prfessinal certificatin, licensure, r emplyability. The student must cmply with legal requirements f the prfessin. This may include prvisins frm Arizna Revised Statutes 41-1758.03 (sectins B and C) regarding the denial f a fingerprint clearance card r being listed n the US gvernment s Office f Inspectr General s Exclusin List. COLLEGE COMMUNICATION The fllwing infrmatin is very imprtant s yu d nt miss any ntices: Cmmunicatin with students strictly thrugh Maricpa Cllege email, nt a persnal email accunt. GateWay Cmmunity Cllege uses a district-wide Ggle pwered email system. This system is the way all fficial Cllege cmmunicatins cncerning selective admissins, class enrllment, financial aid, tuitin due dates and ther imprtant student infrmatin are sent. All students need t check their new student e-mail regularly r frward the new student e-mail t a persnal e-mail t ensure that all fficial cllege cmmunicatin is received. Students may access their new e-mail accunts directly frm their Student Center nce they lg in at my.maricpa.edu. 1st sectin Student Cmmunicatin Center. The benefits t yu include: Quicker respnse Cnvenience. Yu can receive & read email even if ut-f-twn Saves trees! G t my.maricpa.edu & lg in t yur accunt. Click n create an accunt in the paragraph abve the picture f the students t set up yur student accunt. Yu may edit yur infrmatin, such as address, phne, etc. here als if yu need t. This is a self-service fr students, which includes registering fr classes, adding/drpping classes, making payments, printing yur class schedules, viewing financial aid & viewing yur grades. If yu have any technical issues, please call 1-888-994-4433. Physical Therapist Assisting 16 Octber 15-1

STUDENT SERVICES The fllwing are sme f the services available t students. Advising Meeting with a Health Sciences academic advisr in the Center fr Health Careers Educatin (CHCE) is n a walk-in basis n Mndays frm 8 a.m. t 5 p.m. and n Fridays frm 8 a.m. t 1 p.m. (but clsed n Fridays in the Summer). Fr an appintment n Tuesdays-Wednesdays-Thursdays, yu may call 602.286.8600. Bkstre Available are textbks and supplies fr classes, call 602.286.8400. Yu may visit their website at: www.efllett.cm and selecting Cllege Textbks. Cunseling Academic, persnal, r career cunseling available. Call 602.286.8900. Emplyment Upn cmpletin f the Physical Therapist Assisting Prgram, cntact the Career & Re- Entry Services, at 602.286.8500 fr assistance. Financial Aid Available fr qualified students. Cntact the Financial Aid Office at 602.286.8300 r visit website: http://www.gatewaycc.edu/financial-aid Student Assessment Center Services include instructr makeup exams, the English, Math, and Reading COMPASS placement tests, and selected instruments required fr acceptance int the Health Science r Nursing prgrams. Call 602.286.8160 fr specific days and times tests are available. Tutring Assistance Available thugh the Learning Center, 602.286.8800. Fr a cmplete listing f student services, please refer t the cllege catalg, r visit GateWay s website: www.gatewaycc.edu r call cllege infrmatin at 602.286.8000. ESSENTIAL FUNCTIONS The fllwing is a list f physical/mental requirements that are expected f students in the Physical Therapist Assistant Prgram. 1. Demnstrate visual acuity and auditry ability t assess the cnditin f a patient and administer effective patient care. 2. Demnstrate manual dexterity, eye-hand crdinatin, fine and grss mtr skills, and tactile abilities t perfrm functins as directed by the physical therapist and in accrdance with skills utlined in sectin three f the Evaluative Criteria fr the Accreditatin f Physical Therapist Assistant Educatin Prgrams (see attachment). 3. Demnstrate critical thinking and prblem slving skills fr effective patient management and implementatin f selected treatment interventins. 4. Maneuver equipment in a patient s rm r in the physical therapy department in a time efficient manner. 5. Wrk in stressful situatins that require quick thinking and the simultaneus crdinatin f a variety f activities. 6. Demnstrate physical agility t respnd t patient and family needs, including unexpected changes in the patient s status. 7. Demnstrate the physical ability t assist patients in ambulating, psitining in bed, and transferring frm the bed/mat, wheelchair r car in a time efficient manner. 8. Demnstrate prper bdy mechanics fr lifting. 9. Lift bjects in excess f 100 punds with assistance with frequent lifting and/r carrying bjects weighing 50 punds r mre. 10. Tlerate prlnged standing, stping, squatting, bending, pushing, and pulling. 11. Demnstrate ability t read, write, understand and speak English. 12. Demnstrate effective verbal and nn-verbal cmmunicatin skills with internal and external custmers. Students wh are unable t perfrm these functins, with r withut reasnable accmmdatins, may be unsafe in the clinical envirnment and thus will likely be unsuccessful in the prgram. Physical Therapist Assisting 17 Octber 15-1

VOLUNTEER / WORK / OBSERVATION HOURS Frty (40) hurs f vlunteer/wrk/bservatin in physical therapy practice settings are a prerequisite t applicatin fr admissin int the PTA Prgram. A minimum f 20 hurs in an inpatient (hspital, skilled nursing facility, rehabilitatin hspital) setting is required. The vlunteer/wrk/bservatin experience requirement has a tw-fld purpse. First, it assures that the applicant has cmpleted career explratin in the field. The applicant shuld be well aware f the jb duties and respnsibilities f the PTA thrugh the vlunteer/wrk/bservatin and thus be able t make an intelligent decisin abut the apprpriateness f pursuing this career gal. Secnd, the prgram wants t be reasnably certain that students entering the prgram are cmmitted t this career gal. The vlunteer/wrk/bservatin requirement is used t assure that applicants have had first hand experience with the jb duties that a PTA is required t perfrm. The applicant shuld expect that the majrity f facilities nly allw vlunteers t bserve physical therapy practice. Hands n experience is nt allwed in mst facilities. Vlunteer/wrk/bservatin hurs can be gained at a number f facilities which prvide physical therapy services. These facilities include acute care hspitals, skilled nursing units/facilities, rehabilitatin units/hspitals, private practices, business wned practices, schls, and private agencies. It is the respnsibility f the student t arrange fr vlunteer/wrk/bservatin hurs r t certify wrk experience gained in the field. Vlunteer/wrk/bservatin can be arranged by cntacting the physical therapy departments f the types f facilities nted abve. Phne numbers and lcatins f facilities may be fund in the Yellw Pages under the headings Hspitals, Physical Therapy, and Nursing Hmes. Facilities may have a waiting list fr vlunteers and may have limited hurs in which vlunteers can be accmmdated. Applicants ften achieve the required hurs f vlunteer service thrugh attendance at multiple facilities. It is cmmn t cntact a number f facilities befre bservatin can be arranged. Sme rientatin may be required. Allw several weeks t find a facility r facilities t cmplete the 40 hurs. Receiving physical therapy services fr a persnal injury r medical cnditin des nt cunt tward the vlunteer hur requirement. The vlunteer/wrk/bservatin hurs must be certified by a physical therapist r a physical therapist assistant. Please see the Vlunteer/Wrk/Observatin Hurs Verificatin and Assessment Frm included in this packet. One frm is required frm each facility at which wrk/vlunteer experience was cmpleted. VOLUNTEER / WORK / OBSERVATION HOURS VERIFICATION & ASSESSMENT FORM INSTRUCTIONS TO THE APPLICANT - On the attached frm PRINT yur name in the indicated spaces. Give this frm and a stamped, self-addressed envelpe t each Physical Therapist/Physical Therapist Assistant wh has bserved yur perfrmance during yur vlunteer/wrk/bservatin in PHYSICAL THERAPY. Only DIRECT vlunteer/wrk/bservatin in PHYSICAL THERAPY will satisfy the prerequisite requirement. Vlunteer/wrk/bservatin must have ccurred within the past tw years. Make additinal cpies f this frm if yur vlunteer/wrk/bservatin have been perfrmed in mre than ne facility. A separate frm shuld be prvided t each facility. Applicants must submit the Vlunteer/Wrk/Observatin Verificatin and Assessment frm(s) with their applicatin t the prgram. Physical Therapist Assisting 18 Octber 15-1

VOLUNTEER / WORK / OBSERVATION HOURS - VERIFICATION & ASSESSMENT FORM (Page 1 f 3) Applicant's Name Scial Security # r GateWay ID # The abve named applicant is applying fr admissin int the Physical Therapist Assistant Prgram at GateWay Cmmunity Cllege. A prvisin f the Family Educatinal Rights and Privacy Act f 1974 allws students t review the Vlunteer/Wrk/Observatin Verificatin and Assessment frm unless the student waives the right in writing. I waive the right t review this Vlunteer/Wrk/Observatin Verificatin and Assessment Frm. Applicant s Signature Date INSTRUCTIONS FOR PHYSICAL THERAPY VOLUNTEER/ WORK/OBSERVATION SUPERVISOR Please cmplete the frm belw. Frty hurs (40) f vlunteer/wrk/bservatin hurs are required fr admissin int the Physical Therapist Assistant Prgram at GateWay Cmmunity Cllege. The rating and cmments sectins f this frm are used fr student advisement purpses. After cmpleting the frm please mail, the frm t the address prvided belw. T assure cnfidentiality, please sign yur name acrss the back flap f the envelpe. GateWay Cmmunity Cllege Admissins and Recrds 108 N 40th Street Phenix, AZ 85034-1704 I,, d hereby verify that (SUPERVISOR'S NAME - PLEASE PRINT) (APPLICANT'S NAME PLEASE PRINT) hurs f wrk/vlunteer experience in physical therapy at has cmpleted (FACILITY NAME) Supervisr s Signature Date Address City State Zip Cde Wrk Phne Number PT/PTA License r Certificate # State Physical Therapist Assisting 19 Octber 15-1

VOLUNTEER / WORK / OBSERVATION HOURS - VERIFICATION & ASSESSMENT FORM (CONT' D) (PAGE 2 OF 3) Please rate the abve named applicant n their perfrmance during the vlunteer / wrk / bservatin in the fllwing areas. Rating scale = 0-10 with 10 being the highest scre pssible. The ratings n this frm will be used as part f the applicatin prcess t the prgram. Maturity Initiative Prblem-slving Skills Interest in Physical Therapy Prfessinal Manner Persnal Appearance Attendance Interpersnal Cmmunicatin Adaptability Dependability Please cmment belw abut the applicant's perfrmance during their vlunteer/wrk/bservatin at yur facility. Please cmment n the applicant's readiness t enter a Physical Therapist Assistant educatin prgram. Cmments will be used fr student advisement purpses nly. Use additinal paper, if necessary. Signature Date Physical Therapist Assisting 20 Octber 15-1

VOLUNTEER / WORK / OBSERVATION HOURS - VERIFICATION & ASSESSMENT FORM (CONT' D) (Page 3 f 3) The physical therapy vlunteer/wrk/bservatin certified n this frm can best be described as ccurring in the fllwing setting: * NOTE: If several types f experiences were prvided at ne facility, please specify the number f hurs spent in each type f experience. HOURS Acute Care Hspital Rehabilitatin Unit - Hspital based Rehabilitatin Unit - Free standing Outpatient Services - Hspital based Private Practice Sprts Medicine Extended Care Facility Industrial injury rehabilitatin clinic Hme care Pediatric care Schl based physical therapy Cardiac Rehabilitatin Other (please specify) Submit t: GateWay Cmmunity Cllege Admissins & Recrds 108 N 40th Street Phenix, AZ 85034-1704 Physical Therapist Assisting 21 Octber 15-1

Physical Therapist Assisting 22 Octber 15-1

PROGRAM APPLICATION PHYSICAL THERAPIST ASSISTANT 2016 Day Prgram Applicatins accepted frm December 1, 2015 t February 28, 2016 2017 Hybrid Weekend Prgram Applicatins accepted frm July 1 t September 30, 2016 NOTE: It is the applicant s respnsibility t assure that the infrmatin n this applicatin remains current. The applicant must infrm GateWay Cmmunity Cllege f any changes in the infrmatin prvided belw. Failure t prvide current infrmatin may result in the applicant frfeiting their prgram space. Please print clearly: LEGAL NAME LAST FIRST MIDDLE FORMER NAME(S) which may appear n transcript(s) ADDRESS STREET CITY STATE ZIP PHONE NUMBER HOME PHONE NUMBER WORK PHONE NUMBER CELL STUDENT ID NUMBER EMAIL ADDRESS ADMISSION APPLICATION DISCLAIMER: Admissin t the Gateway Cmmunity Cllege Physical Therapist Assistant Prgram des nt guarantee that a student will receive an Assciate in Applied Science Degree frm the cllege. Additinally, cmpletin f the Physical Therapist Assistant Prgram is nt the sle criterin fr btaining a license/certificate t wrk as a physical therapist assistant. Licensing/certificatin requirements, if required, are the exclusive respnsibility f the individual State Bard f Physical Therapy r similar agency, and an individual must satisfy specific requirements f thse agencies independent f graduatin frm the an accredited PTA educatin prgram. CERTIFICATION: I certify that the abve answers are true, crrect and cmplete. I understand that any falsificatin r intentinal misrepresentatin f infrmatin n this applicatin may be cause fr dismissal frm the Physical Therapist Assistant Prgram and frm the cllege. Applicant s Name (PRINT) Signature Date Submit t: GateWay Cmmunity Cllege Admissins and Recrds Office 108 N 40th Street Phenix, AZ 85034-1704 Physical Therapist Assisting 23 Octber 15-1

Physical Therapist Assisting 24 Octber 15-1

PTA ADMISSION APPLICATION CHECKLIST ADVISER REVIEW Last Name First Name Student ID Date The fllwing prerequisites must be cmpleted prir t submitting yur applicatin. In rder fr a curse t satisfy the prerequisite requirements, students must successfully cmplete the fllwing curse with a cumulative PGA 2.4. Applicatins withut this Advisr Review frm cmpleted and signed by a GateWay Cmmunity Cllege General r Healthcare Advisr will nt be accepted. Frty (40) hurs f paid r vlunteer experience in a physical therapy setting supervised by a licensed physical therapist. Curse Curse Title Credits Required Cllege Semester Cmpleted r Enrlled Grade + BIO160 BIO201 Intrductin t Human Anatmy and Physilgy Lec/Lab OR Human Anatmy & Physilgy I 4 + + ENG101 ENG107 First Year Cmpsitin OR First Year Cmpsitin fr ESL 3 The fllwing HCC curses may be taken as prgram prerequisites r cncurrent with required curses, but these curses must be cmpleted prir t clinical if taken cncurrent with required curses. HCC130 HCC130AA HCC130AB HCC130AC HCC130AD HCC130AE HCC130AF Fundamentals in Health Care Delivery (3) OR Health Care Tday (0.5) AND Wrkplace Behavirs in Health Care (0.5) AND Persnal Wellness AND Safety (0.5) AND Cmmunicatin & Team Wrk in Health Care Organizatins (0.5) AND Legal Issues in Health Care (0.5) AND Decisin Making in Health Care Setting (0.5) 3 HCC146 HCC145 Cmmn Medical Terminlgy fr Health Care Wrkers (2) OR Medical Terminlgy fr Health Care Wrkers (3) 2 3 Level One Fingerprint Clearance Card (cpy required) American Heart Assciatin Healthcare Prvider CPR Card Expiratin Date Expiratin Date MCCCD Plicy Backgrund Check Acknwledgement (cpy attached) Student Signature Student Name (printed) Date Adviser Signature Adviser Name (printed) Date Physical Therapist Assisting 25

Physical Therapist Assisting 26 Octber 15-1

Allied Health and Nursing Prgrams Maricpa Cunty Cmmunity Cllege District Summary f Criminal Backgrund Check Requirements effective September 1, 2011 (Student Cpy) Overview f the Requirements In rder fr students t be admitted t r maintain enrllment in gd standing in Maricpa Cunty Cmmunity Cllege District s ( MCCCD ) Allied Health and Nursing prgrams ( Prgrams ) beginning n September 1, 2011, students must prvide with their applicatin t a Prgram all f the fllwing: A cpy f an Arizna Department f Public Safety Level One Fingerprint Clearance Card ( Card ). Students are required t pay the cst f applying fr the Card. Cards that are NOT Level One status will nt be accepted. An riginal versin f the Criminal Backgrund Check Disclsure Acknwledgement frm attached t this Summary signed by the student. At all times during enrllment in a Prgram, students must btain and maintain BOTH a valid Level One Fingerprint Clearance Card and passing dispsitin n supplemental backgrund check perfrmed by MCCCD authrized vendr. Admissin requirements related t backgrund checks are subject t change as mandated by clinical experience partners Implementatin f the Requirements 1. Students that are denied issuance f a Card may be eligible fr a gd cause exceptin thrugh the Arizna Department f Public Safety. It is the student s respnsibility t seek that exceptin directly with the department. Until the student btains a Card and meets the ther requirements fr admissin, he r she will nt be admitted t a Prgram. 2. Students admitted t a Prgram whse Card is revked r suspended must ntify the Prgram Directr immediately and the student will be remved frm the Prgram in which they have been admitted r are enrlled. Any refund f funds wuld be made per MCCCD plicy. 3. The Criminal Backgrund Check Disclsure Acknwledgement directs students t disclse n the data cllectin frm f the MCCCD authrized backgrund check vendr all f the requested infrmatin as well as any infrmatin that the backgrund check may discver. Hnesty is imprtant as it demnstrates character. Lack f hnesty will be the basis fr denial f admissin r remval frm a Prgram if the infrmatin that shuld have been disclsed but was nt wuld have resulted in denial f admissin. Failure t disclse ther types f infrmatin cnstitutes a vilatin f the Student Cde f Cnduct and may be subject t sanctins under that Cde. Students have a duty t update the infrmatin requested n the [backgrund check vendr] data cllectin frm prmptly during enrllment in a Prgram. The [backgrund check vendr] data cllectin frm may ask fr the fllwing infrmatin but the frm may change frm time t time: Legal Name Maiden Name Other names used Scial Security Number Date f Birth Arrests, charges r cnvictins f any criminal ffenses, even if dismissed r expunged, including dates and details. Pending criminal charges that have been filed against yu including dates and details. Participatin in a first ffender, deferred adjudicatin r pretrial diversin r ther prbatin prgram r arrangement where judgment r cnvictin has been withheld. The authrized MCCCD backgrund check vendr will be asked t pass r fail each student based n the standards f MCCCD s clinical experience partners that have established the mst stringent requirements. The sle recurse f any student wh fails the backgrund check and believes that failure may have been in errr is with the backgrund check vendr and nt MCCCD. Summary f Criminal Backgrund Check Requirements.dcx 27

Summary f Criminal Backgrund Check Requirements.dcx 28

(Student: Sign and Attach t Applicatin) ACKNOWLEDGEMENT OF CRIMINAL BACKGROUND CHECK REQUIREMENTS APPLICABLE TO STUDENTS SEEKING ADMISSION INTO ALLIED HEALTH OR NURSING PROGRAMS ON OR AFTER SEPTEMBER 1, 2011 In applying fr admissin t a Nursing r Allied Health prgram ( Prgram ) at the Maricpa Cunty Cmmunity Cllege District, yu are required t disclse n the Arizna Department f Public Safety (DPS) frm all required infrmatin and n the MCCCD authrized backgrund check vendr data cllectin frm any arrests, cnvictins, r charges (even if the arrest, cnvictin r charge has been dismissed r expunged), r participatin in first ffender, deferred adjudicatin, pretrial diversin r ther prbatin prgram n this frm. Additinally, yu must disclse anything that is likely t be discvered in the MCCCD supplemental backgrund check that will be cnducted n yu. Please cmplete the DPS frm, the MCCCD authrized backgrund check vendr frm and any clinical agency backgrund check frm hnestly and cmpletely. This means that yur answers must be truthful, accurate, and cmplete. If yu knw f certain infrmatin yet are unsure f whether t disclse it, yu must disclse the infrmatin, including any arrest r criminal charge. Additinally, By signing this acknwledgement, yu acknwledge the fllwing: I understand that I must submit t and pay any csts required t btain a Level One Fingerprint Clearance Card and an MCCCD supplemental criminal backgrund check. I understand that failure t btain a Level One Fingerprint Clearance Card will result in a denial f admissin t a Prgram r remval frm it if I have been cnditinally admitted. I understand that I must submit t and pay any csts required t btain an MCCCD supplemental backgrund check prir t the start f the class. I understand that failure t btain a pass as a result f the MCCCD supplemental criminal backgrund check will result in a denial f admissin t a Prgram r remval frm it if I have been cnditinally admitted. I understand that, if my Level One Fingerprint Clearance Card is revked r suspended at any time during the admissin prcess r my enrllment in a Prgram, I am respnsible t ntify the Prgram Directr immediately and that I will be remved frm the Prgram. I understand that a clinical agency may require an additinal criminal backgrund check t screen fr barrier ffenses ther than thse required by MCCCD, as well as a drug screening. I understand that I am required t pay fr any and all criminal backgrund checks and drug screens required by a clinical agency t which I am assigned. I understand that the bth the MCCCD supplemental r the clinical agency backgrund check may include but are nt limited t the fllwing: Natinwide Federal Healthcare Fraud and Abuse Databases Scial Security Verificatin Residency Histry Arizna Statewide Criminal Recrds Natinwide Criminal Database Natinwide Sexual Offender Registry Hmeland Security Search By virtue f the MCCCD supplemental backgrund check, I understand that I will be disqualified fr admissin r cntinued enrllment in a Prgram based n my criminal ffenses, the inability t verify my Scial Security number, r my being listed in an exclusinary database f a Federal Agency. The criminal ffenses fr disqualificatin may include but are nt limited t any r all f the fllwing: Scial Security Search Scial Security number des nt belng t applicant Any inclusin n any registered sex ffender database Summary f Criminal Backgrund Check Requirements.dcx 29

Any inclusin n any f the Federal exclusin lists r Hmeland Security watch list Any cnvictin f Felny n matter what the age f the cnvictin Any warrant any state Any misdemeanr cnvictin fr the fllwing N matter age f crime - vilent crimes - burglary - sex crime f any kind including nn - pandering cnsensual sexual crimes and sexual - any crime against minrs, children, assault vulnerable adults including abuse, - murder, attempted murder neglect, explitatin - abductin - any abuse r neglect - assault - any fraud - rbbery - illegal drugs - arsn - aggravated DUI - extrtin Any misdemeanr cntrlled substance cnvictin last 7 years Any ther misdemeanr cnvictins within last 3 years Exceptins: Any misdemeanr traffic (DUI is nt cnsidered Traffic) I understand that I must disclse n all backgrund check data cllectin frms (DPS, MCCCD backgrund check vendr and a clinical agency backgrund check vendr) all required infrmatin including any arrests, cnvictins, r charges (even if the arrest, cnvictin r charge has been dismissed r expunged), r participatin in first ffender, deferred adjudicatin, pretrial diversin r ther prbatin prgram. That includes any misdemeanrs r felnies in Arizna, any ther State, r ther jurisdictin. I als understand that I must disclse any ther relevant infrmatin n the frms. I further understand that nn disclsure f relevant infrmatin n the frms that wuld have resulted in failing the backgrund check will result in denial f admissin t r remval frm a Prgram. Finally, I understand that my failure t disclse ther types f infrmatin f the frms will result in a vilatin f the Student Cde f Cnduct and may be subject t sanctins under that Cde. I understand that, if a clinical agency t which I have been assigned des nt accept me based n my criminal backgrund check it may result in my inability t cmplete the Prgram. I als understand that MCCCD may, within its discretin, disclse t a clinical agency that I have been rejected by anther clinical agency. I further understand that MCCCD has n bligatin t place me when the reasn fr lack f placement is my criminal backgrund check. Since clinical agency assignments are critical requirements fr cmpletin f the Prgram, I acknwledge that my inability t cmplete required clinical experience due t my criminal backgrund check will result in remval frm the Prgram. I understand the Prgrams reserve the authrity t determine my eligibility t be admitted t the Prgram r t cntinue in the Prgram and admissin requirements r backgrund check requirements can change withut ntice. I understand that I have a duty t immediately reprt t the Prgram Directr any arrests, cnvictins, placement n exclusin databases, suspensin, remval f my DPS Fingerprint Clearance Card r remval r discipline impsed n any prfessinal license r certificate at any time during my enrllment in a Prgram. Signature Date Printed Name Student ID Number Desired Health Care Prgram Summary f Criminal Backgrund Check Requirements.dcx 30