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08/14 Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability. 1 PHYSICAL THERAPIST ASSISTANT PROGRAM INFORMATION & APPLICATION PACKET Program Director: Cindy Lavine, PTA, MPH Phone: 817.598.8873 Email: [email protected] Website: www.wc.edu/PTA Role of a PTA: Physical therapist assistants (PTAs) work as part of a team to provide physical therapy services under the direction and supervision of the physical therapist. PTAs implement selected components of patient/client interventions (treatment), obtain data related to the interventions provided, and make modifications in selected interventions either to progress the patient/client as directed by the physical therapist or to ensure patient/client safety and comfort. PTAs assist the physical therapist in the treatment of individuals of all ages, from newborns to the very oldest, who have medical problems or other health-related conditions that limit their abilities to move and perform functional activities in their daily lives. PTAs provide care for people in a variety of settings, including hospitals, private practices, outpatient clinics, home health agencies, schools, sports and fitness facilities, work settings, and nursing homes. PTAs must graduate from a CAPTE-accredited PTA program and licensure or certification is required in most states in which a PTA works. Employment Opportunities: Opportunities exist in a wide variety of practice settings. PTAs may work in hospitals; rehabilitation facilities; out-patient clinics; skilled nursing, extended care or subacute facilities; homes; schools; hospices; education or research centers; industrial, workplace, or other occupational environments; and fitness centers and sports training facilities. According to the Bureau of Labor Statistics Occupational Outlook Handbook, employment of PTAs is expected to grow by 41 percent from 2012 through 2022. Salary: The Bureau of Labor Statistics reports that the national average annual wage for physical therapist assistants was $53,360 in 2013 and the average annual wage in Texas was $68,730. There are considerable geographic differences in salaries, even in Texas. Application Deadline: The application deadline is the first business day of March each year. Applications for admission will be accepted beginning the first business day in December and continuing through the deadline. All testing must be completed prior to the deadline of the first business day of March. Number of Students Admitted to the Program: 20 – The number admitted each year depends on the availability of clinical placements. Program Length: The program begins in the fall semester and students graduate in May, 21 months later.

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Page 1: PHYSICAL THERAPIST ASSISTANT - Weatherford …An additional possible resource is Master the Nursing School & Allied Health Entrance Exams, 19 th ed., 2012, by Gooding, Dreyer, Moss,

08/14

Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

1

PHYSICAL THERAPIST ASSISTANT

PROGRAM INFORMATION & APPLICATION PACKET Program Director: Cindy Lavine, PTA, MPH Phone: 817.598.8873 Email: [email protected] Website: www.wc.edu/PTA

Role of a PTA: Physical therapist assistants (PTAs) work as part of a team to provide physical therapy services under the direction and supervision of the physical therapist. PTAs implement selected components of patient/client interventions (treatment), obtain data related to the interventions provided, and make modifications in selected interventions either to progress the patient/client as directed by the physical therapist or to ensure patient/client safety and comfort.

PTAs assist the physical therapist in the treatment of individuals of all ages, from newborns to the very oldest, who have medical problems or other health-related conditions that limit their abilities to move and perform functional activities in their daily lives.

PTAs provide care for people in a variety of settings, including hospitals, private practices, outpatient clinics, home health agencies, schools, sports and fitness facilities, work settings, and nursing homes. PTAs must graduate from a CAPTE-accredited PTA program and licensure or certification is required in most states in which a PTA works.

Employment Opportunities: Opportunities exist in a wide variety of practice settings. PTAs may work in hospitals; rehabilitation facilities; out-patient clinics; skilled nursing, extended care or subacute facilities; homes; schools; hospices; education or research centers; industrial, workplace, or other occupational environments; and fitness centers and sports training facilities. According to the Bureau of Labor Statistics Occupational Outlook Handbook, employment of PTAs is expected to grow by 41 percent from 2012 through 2022.

Salary: The Bureau of Labor Statistics reports that the national average annual wage for physical therapist assistants was $53,360 in 2013 and the average annual wage in Texas was $68,730. There are considerable geographic differences in salaries, even in Texas.

Application Deadline: The application deadline is the first business day of March each year. Applications for admission will be accepted beginning the first business day in December and continuing through the deadline. All testing must be completed prior to the deadline of the first business day of March.

Number of Students Admitted to the Program: 20 – The number admitted each year depends on the availability of clinical placements.

Program Length: The program begins in the fall semester and students graduate in May, 21 months later.

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

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Licensure, Certification or Registry: PTAs in the State of Texas are licensed by the Texas Board of Physical Therapy Examiners. Some events, such as having a history of substance abuse, being adjudged mentally incompetent by a court of competent jurisdiction or having a felony or misdemeanor conviction that directly relates to the practice of physical therapy MAY disqualify a candidate for licensure. Those crimes which the board considers to be directly related to the duties and responsibilities of a physical therapist assistant include, but are not limited to: 1) any felony which involves an act of fraud, dishonesty, or deceit; 2) any criminal violation of the Physical Therapy Practice Act or other statutes regulating or pertaining to physical therapy or the medical profession; 3) any crime involving moral turpitude; 4) murder; 5) assault; 6) burglary; 7) robbery; 8) theft; 9) rape or sexual abuse; 10) patient/client abuse; 11) injury to an elderly person; 12) child molestation, abuse, endangerment, or neglect; 13) felony conviction for driving while intoxicated, driving under the influence of alcohol or drugs, or driving while ability is impaired; 14) sale, distribution, or illegal possession of narcotics, controlled substances, or dangerous drugs; 15) tampering with a governmental record; or 16) offenses which include attempting or conspiring to commit any of the above offenses. The Board has established a procedure for initiating the review of criminal history for potential licensees. PTA program students or applicants with criminal histories must complete the Criminal History Evaluation Form available on the Board’s website at www.ecptote.state.tx.us (see the link under the Online Services heading) and submit it to the Board for review. There is no need to call the office and speak with an investigator. As mandated by the Legislature, it will cost the individual with the criminal history $50.00 for this review.

Cost: The estimated cost is $9,439 for the two-year program. This includes in-district tuition and fees for all 72 credit hours taken at Weatherford College and an estimate of book costs; out-of-district or out-of-state costs will be higher. If only PTA courses are taken, costs will be lower. The cost of licensure upon graduation is approximately $600. Additional costs will include health insurance, immunizations, CPR certification, uniforms, clinical travel and other miscellaneous expenses.

Acceptance into the Program: Those students who have successfully completed the application procedure and have met all deadlines will be considered for admission. Acceptance into the program is determined by a point system based on:

admission exam score – Test of Essential Academic Skills Version V for Allied Health (TEAS V for AH) academic record

number of general education classes completed (excluding Anatomy & Physiology) Anatomy and Physiology grades (BIOL 2401 & 2402)

references interview writing sample completed at the time of the interview (a response to a prompt evaluated on the basis of grammar,

sentence structure and ability to express thoughts in a written format) Not all applicants will progress to the interview stage of the process; the top thirty, based on point totals prior to the interview, are selected for an interview. Upon completion of the interview and writing sample, acceptance is determined by total numbers of points. The relative weighting of points for each component of the process can be found in the following chart.

Component Percentage TEAS V for AH 30% Number of General Education Courses Completed (excluding A & P) 15% Grades in Anatomy & Physiology 15% References 5% Writing Sample (completed at the interview) 10% Interview 25%

Total 100%

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

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Prerequisites for Admission: The program has selective admissions. In order to be admitted to the PTA Program, students must:

Be admitted to Weatherford College, which includes: Complete an online application to Weatherford College via ApplyTexas at www.applytexas.org Submit official high school and/or college transcripts and request a Transcript Evaluation (if

applicable) Complete the requirements for the college’s Success Initiative Plan. Submit proof of meningitis vaccination, if applicable. For more information/assistance, contact Student Services at 817-598-6241 for assistance with the

admissions process Apply to the Physical Therapist Assistant Program by the first business day in March, which includes:

Complete Allied Health Application, including a valid email address Complete the Test of Essential Academic Skills Version V for Allied Health (TEAS V for AH) at

the Testing Center on the Weatherford Campus before the application deadline. Register for the online exam at 817-598-6383 or 817-598-6439; the cost is $60.00;

Complete forty (40) hours of observation / volunteer / work hours in a physical therapy clinic. Have the appropriate individual complete the Weatherford College Physical Therapist Assistant Program Observation Hours and Reference Form and return it to the Department Chair

Have three (3) persons complete and return a Weatherford College Physical Therapist Assistant Program Reference Form to Karen Wells or Cindy Lavine (a reference form from the same individual who completed the observation / volunteer / work hours form is not acceptable)

Submit copies of transcripts from all colleges attended (student copies are acceptable) Submit proof of the first Hepatitis B vaccine (three dose series) or a positive Hepatitis B titer

Note: While BIOL 2401 & BIOL 2402 are not prerequisites for application to the program, acceptance without

credit for them is provisional; the student must complete BIOL 2401 & BIOL 2402, both with a minimum grade of C, before the PTA Program begins in the fall semester in order to take his/her place in the class.

If already taken, BIOL 2401 & 2402 must have been successfully completed within five years prior to program admission.

All general education courses must be completed with a minimum grade of C. Before being accepted into the Physical Therapist Assistant Program an applicant whose native language

is not English must submit an acceptable score on the TOEFL-iBT. Please see English Proficiency Requirements below.

The application deadline is the first business day in March. Students should complete the above requirements and compile the following in a file folder labeled with their name: 1) Allied Health Application, 2) student or campus copies of transcripts from all other colleges or universities attended, and 3) copy of TEAS V for AH exam scores. Do not include ‘Reference Forms’ and ‘Observation Hours and Reference Forms’; have these sent directly to the Department Chair from the persons completing the forms and they will be added to the applicant’s file when received. After the application deadline, qualified applicants will be contacted by the program to schedule interviews.

English Proficiency Requirements Before being accepted into the Physical Therapist Assistant Program an applicant whose native language* is not English must submit an acceptable score on the TOEFL-iBT. Additional information may be obtained from the Allied Health Department or PTA Program. *A native language is a language that is acquired naturally during childhood and is usually spoken at home, as opposed to a language that is learned later in life; for example, as a part of a person’s formal education.

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

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Additional Admission Information: Beginning in February, weekly email notifications of application status will be sent to all applicants. Applicants who do not receive notifications are advised to check their spam or junk email folders and contact the program director if the emails are not located.

Regarding the Test of Essential Academic Skills Version V for Allied Health (TEAS V for AH): There is not a minimum passing score on this exam. For comparison purposes, average TEAS V for AH scores for the applicant pool will be included in the

weekly email notifications of application status. The exam may be taken twice within a six-month period with at least one week between attempts. Resources for applicants may be found on the ATI website – https://atitesting.com/Solutions/pre-

program.aspx. TEAS V and TEAS V for AH preparation materials are the same. An additional possible resource is Master the Nursing School & Allied Health Entrance Exams, 19th ed.,

2012, by Gooding, Dreyer, Moss, Wilson & George, published by Arco Publishing Company, ISBN# 978-0-7689-3618-6.

Regarding enrollment in BIOL 2401 and/or 2402 at the time of application: For applicants enrolled in BIOL 2401 or 2402 during the spring semester when admission decisions are

made, points will be added to his or her total for the purpose of sorting for interview selection. Applicants are advised to provide proof of enrollment in either of these classes. Admission decisions will be based on the applicant’s final grade in the course; therefore, upon

completion of the course, applicants must provide a transcript or grade report as soon as possible

Additional Requirements, if Accepted: If accepted, students must comply with all school and physical therapist assistant program policies. Program policies are delineated in the Student Handbook. Liability insurance is required and is part of the college fee schedule. Information and specifics on completing the requirements listed below will be made available to the student upon acceptance into the program. Student costs for the requirements vary but could run as much as $400. The cost of the criminal background check and urine drug screen totals approximately $100.00.

Immunizations and/or titers Remaining Hepatitis B vaccines TB screen test Medical clearance Urine drug screen* Criminal background check* Major medical health insurance American Heart Association Health Care Provider CPR certification (to be maintained throughout

program) *After acceptance to the program, new students will authorize and pay for a urine drug screen and criminal background check. These are required for students to go to the various hospitals and agencies for clinical education. Additional background checks or urine drug screens may be required by individual facilities. A positive urine drug screen or a background check positive for certain offenses may prohibit students from participation in clinical experiences. These circumstances would require dismissal of the student from the program due to inability to meet clinical objectives.

Clinicals: Clinical facilities are located in not only in Weatherford and Mineral Wells but also in locations several hundred miles distant from Weatherford College. All students are subject to placement in an ‘away,’ full-time clinical which would require considerable driving or a six-week extended stay in one or more of these locations and additional expense in order to meet clinical objectives.

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

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Ability to Work During the Program: Experience shows that it is very difficult for students to maintain good academic standing while working and attending school. Some students are able to keep part-time employment the first year of the program, especially if they have previously taken some of the general education courses. It becomes increasingly difficult to continue employment as the program progresses due to classroom and clinical demands.

Performance of Program Graduates Graduates of the PTA Program are eligible to take the National Physical Therapy Examination for Physical Therapist Assistants. As program development proceeds and graduates take the exam, pass rates for program graduates will be made available on the program web page. Graduation rates and employment rates will also be available.

Education Options: This two-year PTA associate degree does not fulfill the first two-year requirements of a physical therapy degree and does not necessarily give an applicant preference for acceptance into a physical therapy program. Applicants interested in pursuing a degree in physical therapy are encouraged to investigate admission requirements for the individual physical therapy programs they are considering.

Accreditation Status Effective July 31, 2013, Weatherford College has been granted Candidate for Accreditation status by the Commission on Accreditation in Physical Therapy Education (1111 North Fairfax Street, Alexandria, VA, 22314; phone: 703-706-3245; email: [email protected]). Candidate for Accreditation is a pre-accreditation status of affiliation with the Commission on Accreditation in Physical Therapy Education that indicates that the program may matriculate students in technical/professional courses and that the program is progressing toward accreditation. Candidate for Accreditation is not an accreditation status nor does it assure eventual accreditation.

This Application Packet contains information that is current when published. The College and/or Physical Therapist Assistant Program reserves the right to modify, amend or revise the program, courses, tuition, fees and any

information in this publication.

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

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WEATHERFORD COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM

ABBREVIATED APPLICATION CHECK-LIST Note: This check-list is for your use in completing the application process for the Physical Therapist Assistant Program. Please be advised that it is not a substitute for reading and understanding the information in the Physical Therapist Assistant Program Application Packet. Additionally, it does not address State of Texas testing requirements for enrollment in college (Texas Success Initiative). All applicants are advised to carefully read the entire Application Packet and to seek advisement from the Counseling Center regarding TSI status.

Steps you must complete: Apply to Weatherford College

Complete online application online via ApplyTexas at www.applytexas.org

Have official transcripts from all other colleges or universities attended sent to the Admission’s Office, if applicable

Request a Transcript Evaluation for all other colleges or universities attended, if applicable

Get the meningitis vaccine, if applicable

Apply to the Physical Therapist Assistant Program

Complete Allied Health Application

Take the TEAS V for AH examination

Have three (3) persons complete & mail the Reference Forms

Complete forty (40) hours of observation / volunteer / work hours in a physical therapy clinic or department and have the PT or PTA complete & mail the Observation Hours and Reference Form

Get at least the first Hepatitis B vaccine (three dose series)

Place the following in a file folder and submit the entire folder to one of the locations below: Completed Allied Health Application

Copies of transcripts for all other colleges or universities attended (student copies are acceptable)

If applicable, proof of enrollment in BIOL 2401 or 2402 (if not listed on transcript)

Copy of TEAS V for AH scores

The following need to be mailed directly to one of the addresses below from the persons filling out the forms: Three (3) Reference Forms

Observation Hours and Reference Form

Submit application file and forms to only one of the following persons: Karen Wells Cindy Lavine, PTA, MPH Secretary, ECMW Director, PTA Program Weatherford College Weatherford College 704 Hood Road 704 Hood Road Mineral Wells TX 76067 Mineral Wells TX 76067 817-598-8850 817-598-8873

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

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WEATHERFORD COLLEGE

PHYSICAL THERAPIST ASSISTANT PROGRAM REFERENCE FORM

To: Name Address City, State, Zip

To Whom It May Concern:

The person whose name appears at the bottom of this page is applying to the Weatherford College Physical Therapist Assistant Program and is requesting a personal reference from you. Please complete the form and mail it to one of the following persons before March 1st: Karen Wells Cindy Lavine, PTA, MPH Secretary, ECMW Director, PTA Program Weatherford College Weatherford College 704 Hood Road 704 Hood Road Mineral Wells TX 76067 Mineral Wells TX 76067 817-598-8850 817-598-8873

APPLICANT: Name Phone Number Address City State Zip Code

In order to provide adequate information as to my personal character and qualifications, I authorize the party receiving this form to give full and complete information as requested by the Weatherford College Physical Therapist Assistant Program. I agree that the information requested will become a part of my application file. I further agree that the information will not be disclosed to me, but will be treated as confidential. I waive any right to see this information at any time either prior to, during, or subsequent to my application to the Weatherford College Physical Therapist Assistant Program. I hereby authorize my references to be contacted and to speak freely regarding my qualifications. In that regard, I hold them harmless from any civil actions on my part regarding their comments.

Applicant’s Signature Date

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

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Reference Form, page 2 Considering your knowledge of the applicant, please indicate how much you agree or disagree with each of the statements below by placing a mark in the appropriate space. Feel free to add comments, if you desire.

Strongly

Agree Agree Undecided Disagree

Strongly Disagree

1. Rarely becomes discouraged in a difficult situation Comments:

2. Accepts responsibility & follows through with assigned tasks Comments:

3. Consistently responds appropriately to constructive criticism Comments:

4. Behaves in an ethical manner Comments:

5. Maintains poise in extremely difficult situations Comments:

6. Is tactful, considerate, and gets along well with others Comments:

7. Expresses self in an appropriate, clear & concise manner Comments:

8. Makes decisions after careful & logical gathering of relevant facts Comments:

9. Writes clearly & legibly with good organization of thoughts Comments:

10. Is self-motivated with strong leadership qualities Comments:

General Comments:

Signature Date

Relationship to Applicant Phone Number

Page 9: PHYSICAL THERAPIST ASSISTANT - Weatherford …An additional possible resource is Master the Nursing School & Allied Health Entrance Exams, 19 th ed., 2012, by Gooding, Dreyer, Moss,

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

9

WEATHERFORD COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM

REFERENCE FORM

To: Name Address City, State, Zip

To Whom It May Concern:

The person whose name appears at the bottom of this page is applying to the Weatherford College Physical Therapist Assistant Program and is requesting a personal reference from you. Please complete the form and mail it to one of the following persons before March 1st: Karen Wells Cindy Lavine, PTA, MPH Secretary, ECMW Director, PTA Program Weatherford College Weatherford College 704 Hood Road 704 Hood Road Mineral Wells TX 76067 Mineral Wells TX 76067 817-598-8850 817-598-8873

APPLICANT: Name Phone Number Address City State Zip Code

In order to provide adequate information as to my personal character and qualifications, I authorize the party receiving this form to give full and complete information as requested by the Weatherford College Physical Therapist Assistant Program. I agree that the information requested will become a part of my application file. I further agree that the information will not be disclosed to me, but will be treated as confidential. I waive any right to see this information at any time either prior to, during, or subsequent to my application to the Weatherford College Physical Therapist Assistant Program. I hereby authorize my references to be contacted and to speak freely regarding my qualifications. In that regard, I hold them harmless from any civil actions on my part regarding their comments.

Applicant’s Signature Date

Page 10: PHYSICAL THERAPIST ASSISTANT - Weatherford …An additional possible resource is Master the Nursing School & Allied Health Entrance Exams, 19 th ed., 2012, by Gooding, Dreyer, Moss,

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

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Reference Form, page 2 Considering your knowledge of the applicant, please indicate how much you agree or disagree with each of the statements below by placing a mark in the appropriate space. Feel free to add comments, if you desire.

Strongly

Agree Agree Undecided Disagree

Strongly Disagree

1. Rarely becomes discouraged in a difficult situation Comments:

2. Accepts responsibility & follows through with assigned tasks Comments:

3. Consistently responds appropriately to constructive criticism Comments:

4. Behaves in an ethical manner Comments:

5. Maintains poise in extremely difficult situations Comments:

6. Is tactful, considerate, and gets along well with others Comments:

7. Expresses self in an appropriate, clear & concise manner Comments:

8. Makes decisions after careful & logical gathering of relevant facts Comments:

9. Writes clearly & legibly with good organization of thoughts Comments:

10. Is self-motivated with strong leadership qualities Comments:

General Comments:

Signature Date

Relationship to Applicant Phone Number

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

11

WEATHERFORD COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM

REFERENCE FORM

To: Name Address City, State, Zip

To Whom It May Concern:

The person whose name appears at the bottom of this page is applying to the Weatherford College Physical Therapist Assistant Program and is requesting a personal reference from you. Please complete the form and mail it to one of the following persons before March 1st: Karen Wells Cindy Lavine, PTA, MPH Secretary, ECMW Director, PTA Program Weatherford College Weatherford College 704 Hood Road 704 Hood Road Mineral Wells TX 76067 Mineral Wells TX 76067 817-598-8850 817-598-8873

APPLICANT: Name Phone Number Address City State Zip Code

In order to provide adequate information as to my personal character and qualifications, I authorize the party receiving this form to give full and complete information as requested by the Weatherford College Physical Therapist Assistant Program. I agree that the information requested will become a part of my application file. I further agree that the information will not be disclosed to me, but will be treated as confidential. I waive any right to see this information at any time either prior to, during, or subsequent to my application to the Weatherford College Physical Therapist Assistant Program. I hereby authorize my references to be contacted and to speak freely regarding my qualifications. In that regard, I hold them harmless from any civil actions on my part regarding their comments.

Applicant’s Signature Date

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

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Reference Form, page 2 Considering your knowledge of the applicant, please indicate how much you agree or disagree with each of the statements below by placing a mark in the appropriate space. Feel free to add comments, if you desire.

Strongly

Agree Agree Undecided Disagree

Strongly Disagree

1. Rarely becomes discouraged in a difficult situation Comments:

2. Accepts responsibility & follows through with assigned tasks Comments:

3. Consistently responds appropriately to constructive criticism Comments:

4. Behaves in an ethical manner Comments:

5. Maintains poise in extremely difficult situations Comments:

6. Is tactful, considerate, and gets along well with others Comments:

7. Expresses self in an appropriate, clear & concise manner Comments:

8. Makes decisions after careful & logical gathering of relevant facts Comments:

9. Writes clearly & legibly with good organization of thoughts Comments:

10. Is self-motivated with strong leadership qualities Comments:

General Comments:

Signature Date

Relationship to Applicant Phone Number

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

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WEATHERFORD COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM

OBSERVATION HOURS FORM

APPLICANT: Name Phone Number Address City State Zip Code

In order to provide adequate information as to my personal character and qualifications, I authorize the party receiving this form to give full and complete information as requested by the Weatherford College Physical Therapist Assistant Program. I agree that the information requested will become a part of my application file. I further agree that the information will not be disclosed to me, but will be treated as confidential. I waive any right to see this information at any time either prior to, during, or subsequent to my application to the Weatherford College Physical Therapist Assistant Program. I hereby authorize my references to be contacted and to speak freely regarding my qualifications. In that regard, I hold them harmless from any civil actions on my part regarding their comments.

Applicant’s Signature Date

VERIFICATION OF HOURS:

Facility Name Phone #

Facility Address

Dates of Observation Total # of hours

or Dates of Employment Total # of hours

Job Title

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Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

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OBSERVATION HOURS – REFERENCE FORM: Considering your knowledge of the applicant’s behavior while observing / volunteering / working in your facility, please indicate how much you agree or disagree with each of the statements below by placing a mark in the appropriate space. Feel free to add comments, if you desire.

Please complete the form and mail it to one of the following persons before March 1st: Karen Wells Cindy Lavine, PTA, MPH Secretary, ECMW Director, PTA Program Weatherford College Weatherford College 704 Hood Road 704 Hood Road Mineral Wells TX 76067 Mineral Wells TX 76067 817-598-8850 817-598-8873

Strongly Agree

Agree Undecided Disagree Strongly Disagree

1. Well groomed, neat & clean, dressed appropriately Comments:

2. Always arrives at prearranged times Comments:

3. Expresses self in a clear, concise & appropriate manner Comments:

4. Maintains composure under difficult conditions Comments:

5. Listens well, asks for further clarification as needed Comments:

6. Displays enthusiasm and interest in physical therapy Comments:

General Comments:

Supervising Physical Therapist or Physical Therapist Assistant:

PT / PTA License # Please Print Name circle one Signature Date

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ALLIED HEALTH APPLICATION

Answer ALL questions. Please type or print. Mail to appropriate campus listed on bottom of second page with all required paperwork. ===============================================================================

SPECIALTY FOR WHICH APPLICATION IS MADE: [ ]-Associate Degree Nursing [ ]-Fall Class [ ]-Spring Class – Main Campus Weatherford [ ]-Associate Degree Nursing [ ]-Fall Class – Wise County Campus [ ]-Diagnostic Medical Sonography – Main Campus Weatherford [ ]-Human Service Provider [ ] A.A.S. – Main Campus Weatherford [ ]-LVN-RN Transition– Main Campus Weatherford [ ]-Occupational Therapy Assistant – Mineral Wells Education Center [ ]-Phlebotomy Technology [ ]-Fall Class [ ]-Spring Class [ ]-Summer Class– Main Campus Weatherford [ ]-Physical Therapist Assistant – Mineral Wells Education Center [ ]-Radiology Technology– Main Campus Weatherford [ ]-Respiratory Care– Main Campus Weatherford [ ]-Substance Abuse Counseling [ ] Certificate– Main Campus Weatherford [ ]-Vocational Nursing [ ]-Fall Class [ ]-Spring Class– Main Campus Weatherford =============================================================================== Name: [ ] Mr. [ ] Miss [ ] Mrs. First Middle Last Maiden Name Mailing Address: Number & Street City State Zip Permanent Address (if different from above) Texas County of Residence___________________________ Country of Citizenship Social Security # Country of Birth Home Phone: ( ) Cell Phone: ( ) Business Phone: ( ) E-mail address: In case of emergency notify: Name Relationship Address: Phone ( ) Number and Street City State Zip Have you ever been convicted or received deferred adjudication for a felony/misdemeanor? yes no Note: If you pled “nolo contendere, or no contest,” you must answer “yes.” If you answered “yes” to the above question, you must report charges and disposition to certification or licensing agency in order to determine eligibility for taking certification or licensure examination. ===============================================================================================

PROFESSIONAL LICENSES OR CERTIFICATION =============================================================================================== Type Issued By Number Date ===============================================================================================

(Page 1 of 2-Please complete the reverse side of this form)

Page 16: PHYSICAL THERAPIST ASSISTANT - Weatherford …An additional possible resource is Master the Nursing School & Allied Health Entrance Exams, 19 th ed., 2012, by Gooding, Dreyer, Moss,

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=============================================================================================== EDUCATION – List ALL Colleges and Universities Attended

=============================================================================================== NAME OF SCHOOL LOCATION OF SCHOOL DATES:

FROM/TO DIPLOMA/ DEGREE OR CERTIFICATE

MAJOR/MINOR

HIGH SCHOOL OR GED

COLLEGE/UNIVERSITY

COLLEGE/UNIVERSITY

COLLEGE/UNIVERSITY

TECHNICAL OR OTHER

** The Registrar of Weatherford College must receive official transcript(s) before this application can be processed. ===============================================================================================

WORK EXPERIENCE =============================================================================================== List current or most recent job: 1. Name of Company Complete Address Telephone No. ( ) Supervisor's Name Title Dates Employed: From to Nature of Job Duties Starting Salary Final Salary Reason for Leaving ===============================================================================================

FOLLOW UP INFORMATION =============================================================================================== It is important that we do a follow-up study of our students. Please provide the following information about two (2) people who will always know where to locate you. Name Complete Mailing Address Telephone No. 1. Email Address _________________________________________________________________________ 2. Email Address _________________________________________________________________________ ===============================================================================================

PLEASE READ AND SIGN THE FOLLOWING =============================================================================================== I hereby certify that the information contained in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or falsification of information is cause for denial of admission or dismissal from the program. Signature of Applicant Date Weatherford College is an Equal Opportunity institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.

Please include all required paperwork with your application. Incomplete applications will not be accepted. Weatherford College (main campus) Weatherford College Mineral Wells Education Center Weatherford College Wise County Allied Health Division Allied Health Division Allied Health Division 225 College Park Drive 704 Hood Road 307 S. Cates Weatherford, TX 76086 Mineral Wells, TX 76067 Decatur, TX 76234 (817) 594-5471 or (800) 287-5471 (940) 325-2591 or (800) 300-2591 (940) 627-2690 or (800) 287-5471 Fax: (817) 598-6455 Fax: (940) 328-1800 Fax: (940) 627-0623