Physical Therapist Assistant Program Program Application Applications Available: vember, 2017 Application Deadline: March 15, 2018 Program Start: Fall, 2018 ADMISSION REQUIREMENTS Attend an information seminar. Please visit www.aacc.edu/cache/pta for dates and times. Admission and selection information will be reviewed. Submitted an official high school transcript or GED equivalency transcript and college transcripts (if applicable) to the Health Sciences Office (FLRS 100) by May 3, 2018. (To be considered official, transcripts must be in the institution s original, sealed envelope.) Demonstrated eligibility for ENG 111 or show current enrollment in the non-credit developmental English course(s) needed for eligibility. Students must demonstrate successful completion of such course(s) by the end of the spring semester to be eligible for the May selection. Demonstrated eligibility for MAT 137 or show current enrollment in the non-credit developmental math course(s) needed for eligibility. Students must demonstrate successful completion of such course(s) by the end of the spring semester to be eligible for the May selection. Satisfactorily completed the chemistry academic requirement or show current enrollment in a chemistry course with a grade of C or better (credit or non-credit). Students must demonstrate successful completion of this course by the end of the spring semester to be eligible for the May selection. Following review of applications, students will receive a letter regarding the status of their application. IMPORTANT INFORMATION A mandatory meeting will be held on Wednesday, April 25, 2018 from 2:00 p.m. to 4:00 p.m., Room TBA. The purpose of this meeting is to review the selection process and provide information regarding the required Health Examination Record and other program requirements. All students who are seeking admission to the fall 2018 class must attend this meeting and remain for the entire meeting. Students who are unable to attend this meeting must contact the Health Sciences Admissions Assistant at 410-777-7070 or email healthsciencesadmissions@aacc.edu in advance of the meeting. The Health Sciences Admissions Assistant will process applications. Direct all inquiries regarding transcripts, or other records related to the selection process to the Admissions Assistant by calling 410-777-7070 or email dahopp@aacc.edu. For selection, qualified applicants will be classified in one of the following categories: o Conditional Acceptance Those applicants who have successfully met the academic requirements by the end of the spring semester and are conditionally selected based on the program selection criteria. o Wait List Those applicants who have successfully met the admission criteria but there are no seats available. These applicants will be notified of selection if and when a seat becomes available. o Final Acceptance Those applicants who have been conditionally accepted and have submitted complete health examination records, submitted a satisfactory criminal background check and registered for or submitted valid CPR certification. This program is competitive and seats are limited; therefore, not all qualified candidates will be selected.
NOTE: All health sciences students who are offered admission and/or clinical placement will be required to submit to a complete criminal background check and urine drug screen. All student applicants final acceptance in the program shall be contingent upon satisfactory completion of a criminal background check. All letters of acceptance shall state that the acceptance is conditional and contingent on submission to a criminal background check and urine drug screen as may be required by the program--that results in satisfactory reports. If an accepted student tests positive for an illegal or un-prescribed drug, the student shall be denied admission or terminated from any health sciences program. Separate, additional criminal background checks and urine drug screens may be required by clinical sites prior to placements. Students with an unsuccessful background check or urine screening who is denied by a clinical site that is required to meet program competencies shall be dismissed from the program and their registrations shall be withdrawn from courses related to the program of study. If the student tests positive for an illegal or un-prescribed drug, the student shall be denied admission or terminated from any health sciences program even if a denied placement was not required to meet program competencies. Successful reports of criminal background checks and urine drug screens do not assure eligibility for specific clinical site placement, program completion, and/or eligibility to sit for professional licensure/board examinations. Students are reminded that licensing boards for certain health care occupations and professions may deny, suspend, or revoke a license or may deny the individual the opportunity to sit for an examination even if the individual has completed all program course work if it is determined that an applicant has a criminal history or has been convicted of, or pleads guilty, or pleads nolo contendere or the like to a felony or other serious crime. Successful completion of a health sciences program of study at Anne Arundel Community College does not guarantee licensure, the opportunity to sit for a licensure examination, certification or employment in the relevant health care occupation. Students may be automatically denied admission or, if enrolled, dismissed from the program if they have not been truthful or have provided inaccurate information on the application or on any other form or submission. Students who have questions or concerns are encouraged to contact the Health Sciences Admissions Office at healthsciencesadmissions@aacc.edu. * twithstanding the statements herein regarding urine drug screens, as of September 2010, only certain programs will be requiring drug screening. AACC shall inform students which programs presently require them. However, AACC, at any time, has the right, upon notice, to require any and all students and any and all programs to comply with drug screening. G:\ALHEALTH\HDrive\AHCOMMON\TDN\Applications\PTA\2018 Application\PTA Application Cover Sheet.docx
CHESAPEAKE AREA CONSORTIUM FOR HIGHER EDUCATION Anne Arundel Community College * Chesapeake College * College of Southern Maryland PHYSICAL THERAPIST ASSISTANT FALL 2018 Application Deadline March 15, 2018 Program Application DEMOGRAPHIC INFORMATION (Please print) Last Name First Name Middle Address City State Zip Code County of Residence Last 4 digits of social security # College ID #: The mailing address you provide will be your address of record. It is your responsibility to notify the Health Sciences Office of name, address and phone number changes during the application process. Home Phone Cell Phone Work Phone AACC Email Address Required other email is acceptable By signing below, I agree/understand the following: @mymail.aacc.edu Admission/Academic Requirement Checklist 1. I have an active admission status at AACC and am in Good Standing (2.0 GPA>) with the college. 2. I must submit final official transcripts from previously attended colleges from which I am transferring courses toward the PTA program by the stipulated deadline and, if needed, high school transcript. International students must submit official transcript evaluation report from ECE or WES to verify /authenticate your high school and/or college transcripts by the stipulated deadline. 3. I have submitted the Address Verification Form with this application including two supporting documents. 4. Photo copy of driver s license or other government issued photo ID, or AACC photo ID is attached. 5. If information is incomplete/missing from my application or file, it will NOT be processed and will be returned to me. SIGNATURE: DATE:
ADMISSION/ACADEMIC REQUIREMENTS CHEMISTRY Completed a chemistry course with lab and earned a grade of C or better. U.S. High School Chemistry (1 credit) or CHE 011 (2 equivalent hours) or CHE 103 / 111 If from high school, you MUST submit a final *official high school transcript. *All Official transcripts are received by Anne Arundel Community College in the sending institution s original sealed envelope. If home schooled, the high school curriculum must be under a recognized umbrella organization with the supervision of a state approved curriculum. AACC may require a course syllabus so that our chemistry department chair can review and approve the curriculum. School where you completed the chemistry requirement: SEMESTER/Year: GRADE: TOEFL EXAM (If applicable) (Native Language NOT English) SEMESTER: SCORE/GRADE: Where Completed: MUST SUBMIT ONE OF THE FOLLOWING: *Official High School/GED transcript including date of graduation and chemistry grade if applicable. *Official college transcript verifying date AA degree or higher was conferred. Print the name of the institute you are submitting a transcript from on the line below: *Official transcripts are received by Anne Arundel Community College in the sending institution s original sealed envelope. A mandatory meeting for all applicants is scheduled on Wednesday, April 25, 2018 from 2:00 pm to 4:00 pm. Location, TBD All students seeking admission to the fall 2018 class must attend this meeting and remain for the entire meeting. Failure to attend this meeting without prior notification will eliminate you from consideration into the fall 2018 PTA program. It is your responsibility to check your email account for notifications from the Health Sciences Admissions Office.
GENERAL EDUCATION COURSES Must be completed with a C or better LAST NAME: COURSE GRADE CREDITS Human Biology 1 BIO 231 and Human Biology 2 BIO 232 FIRST NAME: COLLEGE WHERE COMPLETED TERM AND YEAR COMPLETED OR A & P 1 BIO 233 and A & P 2 BIO 234 ENG 111/115 or 121 Introduction to Psychology PSY 111 Developmental Psychology PSY 211 College Algebra MATH 137 Previous math 121, 131, 141, 142, 151 or 191 will be accepted. other math is acceptable for this program. Arts/Humanities Elective (Gen Ed Requirement from catalog List Course: te: It is your responsibility to indicate any courses listed above that you are currently enrolled in during the spring 2018 term. You may not receive points for courses you do not disclose on this application. BACKGROUND INFORMATION
BACKGROUND INFORMATION Submit explanation of questions for which you answer "yes" and provide documents relating to your answer in a sealed envelope attached to this application. Attention: Tammie Neall Do not write explanation(s) on the application. Were you ever disciplined for any academic or behavior/conduct issue by any college, university, or any other educational institution after High School including, but not limited to, probation, dismissal, suspension, disqualification, or imposition of a failing grade as a disciplinary sanction? If your answer is yes provide a written explanation and all relevant documents relating thereto. Have you ever been convicted of a crime, driving while intoxicated or impaired (either by alcohol or drugs), had your driving privileges suspended or revoked, and/or are there any pending charges regarding any of the above? If your answer is yes provide a written explanation and all relevant documents relating thereto. Have you ever surrendered your driver's license or had such license suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto. Have you ever surrendered a professional license, certification or registration, or had one restricted, suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto. Have you ever been placed on professional probation, had conditions or limitations placed on your ability work even if your license had not been restricted, suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto Have you ever had your clinical privileges at any office or facility restricted, suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto NOTE: Licensing boards for certain health care occupations, including PTA, may deny, suspend, or revoke a license or may deny the individual the opportunity to sit for an examination even if the individual has completed all program course work, if it is determined that an applicant has a criminal history or is convicted or pleads guilty or nolo contendere to a felony or other serious crime. If applicable, it is recommended to contact the Maryland Board of Physical Therapy for clarification at 410-764-4752. I certify that the information on this application is true and accurate to the best of my knowledge. I am aware that falsification or misrepresentation may result in being denied admission, or if enrolled, dismissed from this program. I understand that final acceptance into the PTA program shall be contingent upon satisfactory completion of a criminal background check and satisfactory completion of a health examination record. Signature: Date: PRINT NAME: RESS VERIFICATION
ADDRESS VERIFICATION The Address Verification Form is part of the application packet and must be completed in its entirety with two supporting documents. Applications received without this form and documentation will be considered incomplete and will be returned to the applicant. Consideration will be given only to candidates whose verified resident address is in Anne Arundel County for at least three months prior to the date the application is submitted. Questions pertaining to this form can be addressed to Melissa Mumma in the Records Office at 410-777-2721. NOTE: OUT OF COUNTY/STATE APPLICANTS WILL BE REVIEWED ONLY WHEN SPACE IS AVAILABLE. tice of ndiscrimination: AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support Services, 410-777-2306 or Maryland Relay 711, 72 hours in advance to request most accommodations. Requests for sign language interpreters, alternative format books or assistive technology require 30 days notice. For information on AACC s compliance and complaints concerning sexual assault, sexual misconduct, discrimination or harassment, contact the federal compliance officer and Title IX coordinator at 410-777-1239, complianceofficer@aacc.edu or Maryland Relay 711.
Anne Arundel Community College 101 College Parkway Arnold, Maryland 21012-1895 VERIFY SP18 410-777-2243 ADDRESS VERIFICATION FOR PHYSICAL THERAPIST ASSISTANT APPLICANTS Directions: This form must be completed entirely and documents submitted as part of the health sciences program application process. If you the student support yourself, provide a minimum of two of the documents listed below in your name, at current resident address that are dated three months prior to the application deadline date. OR If for the most recent 12 months, you, the student, have resided in Anne Arundel county, but are supported by someone in another Maryland county or state, provide a minimum of two of the documents listed below in your name, at current resident address that are dated three months prior to the application deadline date. OR If for the most recent 12 months, another person(s) has provided one-half or more of your financial support, provide a minimum of two documents listed below in your supporter s name, showing current resident address that are dated three months prior to the application deadline date. In addition, you will need to provide one document from the list below in your name showing your current resident address and dated three months prior to the application deadline date in addition to the two documents from your supporter. The supporter must also complete the information requested in Section B. Military Personnel Only: Complete this form with a copy of your military ID (also dependent ID, if spouse or dependent), copy of orders, and a copy of housing assignment, lease, deed or utility bill showing your resident address. Example: All documents must be dated three months prior to application submission date. Acceptable Documents: Maryland Driver s License Voter Registration Card Copy of Deed of Trust or Signed Lease Maryland Withholding Form MW 507 (not U.S. W-2) Maryland Income Tax Return (not U.S.) Utility Bill: gas, electric, water, phone, cable, etc. Vehicle Registration Card The college reserves the right to request additional information and documentation as necessary. SECTION A TO BE COMPLETED BY STUDENT 1. Student Name Student ID or SSN 2. Resident Address City, State, Zip County Day Phone: Evening: 3. Dates of occupancy at above address _ 4. Previous Address City, State, Zip How long did you live at this previous address? Own Rent 5. Are you registered to vote? 6. Do you possess a valid driver s license? County and State
If yes, in what state issued? County Date of Issuance 7. Do you own a motor vehicle? If yes, in what state issued? County Date of Issuance 8. Do you have the use of another person s motor vehicle? If yes, provide name Relationship to student 9. Are you paying Maryland income tax for this year on all earned income? If yes, which county? 10. List where you have filed income tax returns for the past two (2) years. 20 State County 20 State County 11. If employed, is Maryland income tax currently being withheld? If yes, which county? 12. For the most recent 12 months, has another person(s) provided one-half or more of your financial support? * * If the answer to question 12 is, SECTION B (next page) must be completed by your supporter. Additional information: The college reserves the right to request additional information and documentation if necessary. I CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS CORRECT TO THE BEST OF MY KNOWLEDGE. Signature of Student (required) OFFICE USE ONLY ACCEPTABLE DOCUMENTS: MILITARY / BRAC WAIVER: 1. MD driver s license 1. Military ID (& Dependent ID, if spouse or dependent) 2. MD income tax return (not U.S.) 2. Copy of orders 3. Voter registration card 3. Copy of housing assignment, lease, deed, or 4. Vehicle registration utility bill showing resident address 5. Utility bill showing home address 6. Copy of deed of trust or signed lease 7. MD withholding form MW 507 (not U.S. W-2) Date STATUS OF RESIDENT ADDRESS Anne Arundel county Other MD county Out-of-State Term & Year Authorized Signature Date
SECTION B TO BE COMPLETED BY SUPPORTER IF ANSWER TO QUESTION 12 IN STUDENT SECTION IS YES 1. Name of Supporter Relationship to Student 2. Supporter s Address City, State, Zip County Day Phone: Evening: 3. Dates of occupancy at above address 4. Previous Address City, State, Zip How long did you live at this previous address? Own Rent 5. Are you registered to vote? County 6. Do you possess a valid driver s license? If yes, in what state issued? County Date of Issuance 7. Do you own a motor vehicle? If yes, in what state issued? County Date of issuance 8. Do you have the use of another person s motor vehicle? If yes, provide name Relationship to student 9. Are you paying Maryland income tax for this year on all earned income? If yes, which county? 10. List where you have filed income tax returns for the past two (2) years. 20 State 20 State 11. If employed, is Maryland income tax currently being withheld? If yes, which county? Additional Information: The college reserves the right to request additional information and documentation if necessary Signature of Supporter Date tice of ndiscrimination: AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support Services, 410-777-2306 or Maryland Relay 711, 72 hours in advance to request most accommodations. Requests for sign language interpreters, alternative format books or assistive technology require 30 days notice. For information on AACC s compliance and complaints concerning sexual assault, sexual misconduct, discrimination or harassment, contact the federal compliance officer and Title IX coordinator at 410-777-1239, complianceofficer@aacc.edu or Maryland Relay 711.