I. IDENTIFYING INFORMATION DOCTOR OF PHYSICAL THERAPY (DPT) PROGRAM APPLICATION FOR ADMISSION OFFICE OF ADMISSIONS 5414 Brittany Drive, Baton Rouge, Louisiana 70808 (225) 768-1700 Today s Date: Social Security Number: Birth Date MM/DD/YY: / / Last Name: First Name: Middle Name: Maiden Name: Other Name(s) under which your education records may be filed: Mailing Address: City: State: Zip: How long have you lived in the state listed above? years Email: Phone (H): Phone (W): Cell(c): II. DEMOGRAPHIC INFORMATION Are you Hispanic/Latino? Yes No Check all that characterize your race. (Note: regardless of you answer to the previous question, please mark one or more races to indicate what you consider yourself to be.) GENDER: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Male Female MARITAL STATUS: Married Single Divorced Widowed RELIGIOUS AFFILIATION: Catholic Christian/Non-Catholic Jewish Other Undisclosed Unknown 1
US CITIZEN (check one): Yes No If no, give alien registration number: Country of Birth: Driver s License No.: State: Date Licenses issued: III. FAMILY INFORMATION PERSON TO NOTIFY IN CASE OF EMERGENCY: Relationship: Name: Phone:( ) Address (if different from above): City: State: Zip: If parent/spouse, how long have they live in the state listed above? years IV. EDUCATION INFORMATION EDUCATION EXPERIENCES The GRE must have been taken within the last five (5) years. Submit official copy of GRE scores to Office of Admissions. Test Date: GRE GRE Test Score: Verbal: Quantitative: Analytical or Analytical Writing: Verbal: Quantitative: Analytical or Analytical Writing: POST SECONDARY INSTITUTIONS List all formal education beyond high school, including Franciscan Missionaries of Our Lady University. Attach an additional sheet if necessary. Submit official transcripts to Office of Admissions. GPA: Credits/Degrees Earned GPA: Credits/Degrees Earned GPA: Credits/Degrees Earned GPA: Credits/Degrees Earned 2
V. OBSERVATION HOURS INFORMATION List all observation hours performed under a licensed physical therapist. You must also have the physical therapist fill out a documentation of observation form and submit to the admissions office. VI. EMPLOYMENT INFORMATION List all work experience, both full and part-time, during the last five years. Attach an addition sheet if necessary. Job Responsibilities Job Responsibilities Job Responsibilities Job Responsibilities 3
VII. PROFESSIONAL MEMBERSHIPS: List all professional membership and service organization involvement. VIII. LETTERS OF RECOMMENDATIONS List two (2) individuals who you will ask to provide references. References should come from: 1) Physical Therapist, and 2) Employer or professor. Person writing this reference must mail reference to Office of Admissions in a sealed envelope. (1) Name: Address: (2) Name: Address: IX. PERSONAL STATEMENT Submit an essay/personal statement along with this application form describing: 1) Why you are interested in the field of physical therapy; 2) Your own personal strengths and weaknesses; 3) Your longterm career goals; and 4) Why you feel Franciscan Missionaries of Our Lady University Doctor of Physical Therapy program is a good fit for you. 4
X. CERTIFICATION AND AGREEMENT: (Must be completed by all applicants) * PLEASE READ CAREFULLY * Please answer the following questions. If your answer is yes to any of the following, please attach an explanation. Have you ever been arrested, charged with, convicted of, pled guilty or not contest to, or been sentenced for any criminal offense in any state? Have you ever had disciplinary action pending or taken regarding any health license, certification registration or permit you hold or have held? Have you ever been denied a license, certification, registration or permit to practice in a regulated health occupation? Have you even been denied staff membership or privileges in any hospital or healthcare facility or had such membership revoked, suspended or subjected to any restrictions, probation or other type of discipline? Have you ever had a malpractice judgment against you or settled a malpractice action? Have you ever been disciplined for academic performance or conduct violations by any college/university/school? If you have answered YES to any of the previous questions, please provide a brief explanation below. 5
BY MY SIGNATURE, I CERTIFY: 1. To the best of my knowledge, all information on this application is complete and accurate. I understand that giving false or incomplete information will make me ineligible for admission to Franciscan Missionaries of Our Lady University. Moreover, I understand that discovery of false information or omission of information will result in immediate dismissal from the University. 2. I do herby authorize Franciscan Missionaries of Our Lady University to investigate my personal history, past/present employment and/or education background. 3. I certify that (if applicable) I have registered (or will register) with the selective service. 4. I am aware that Franciscan Missionaries of Our Lady University is a Catholic Institution committed to graduate programs which provide the basics for excellence in the practice of health care and which constitute a solid foundation for student academic and personal development. Students are expected to strive for academic excellence and clinical competence with emphasis on the art of human caring. I agree to strive to meet the expectations set forth in the mission of Franciscan Missionaries of Our Lady University. Signature of Applicant Date RETURN THIS APPLICATION WITH A NON-REFUNDABLE $50 APPLICATION FEE TO: FRANCISCAN MISSIONARIES OF OUR LADY UNIVERSITY OFFICE OF ADMISSIONS 5414 BRITTANY DRIVE BATON ROUGE, LOUISIANA 70808 Graduation from a physical therapist education program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE), 1111 North Fairfax Street, Alexandria, VA 22314; phone; 703-706-3245; accreditation@apta.org is necessary for eligibility to sit for the licensure examination, which is required in all states. Franciscan Missionaries of Our Lady University is seeing accreditation of a new physical therapist education program from CAPTE. On November 30, 2017, the program submitted an Application for Candidacy, which is the formal application required in the pre-accreditation stage. Submission of this document does not assure that the program will be granted Candidate for Accreditation status. Achievement of Candidate for Accreditation status is required prior to the implementation of the professional phase of the program; therefore, no students may be enrolled in professional courses until Candidate for Accreditation status has been achieved. Further, though achievement of Candidate for Accreditation status signifies satisfactory progress toward accreditation, it does not assure that the program will be granted accreditation. 6