DPT Supplemental Application 2018

South College
School of Physical Therapy
ATTN: DPT ADMISSIONS
400 Goody's Lane
Knoxville, TN 37922

SECTION I: BIOGRAPHICAL INFORMATION
Title:
Full Legal Name:*
Under what other name(s) might documents be received?
Marital Status:
Age:*
Date of Birth:*
Place of Birth:*
Social Security Number:*
Race:*
Sex:*
Telephone number at which you can be reached between 8:00am and 5:00pm:
-
Home Phone:
-
Cellular Phone:
-
E-mail Address:
Alternate Email Address:
Permanent Address:
Temporary Address:
Preferred mailing address:
County and state of legal residence:
Employed by:
Occupation:
Business Phone:
-
Emergency Contact Name:
Relationship:
Emergency Contact Address:
Emergency Contact Phone:
-
Are you a United States Citizen?
If No, indicate Legal Status:

*INFORMATION NEEDED FOR STATISTICAL REPORTING TO THE DEPT. OF EDUCATION

From among the following, please select the type of geographical area where you were raised:

From among the following statements, please select all that apply to you.

I graduated from a high school from which a low percentage of seniors receive a high school diploma.
I graduated from a high school at which many of the enrolled students are eligible for free or reduced price lunches.
I am from a family that receives public assistance (e.g., Aid to Families with Dependent Children, food stamps, Medicaid, public housing), or I receive public assistance.
I am from a family that lives in an area that is designated as a Health Professional Shortage Area, or a Medically Underserved Area.
I participated in an academic enrichment program funded in whole or in part by the Health Careers Opportunity Program.
I am a high-school dropout who received adult high school diploma or GED.
I am from a school district where 50% or less of graduates go to college, or where college education is not encouraged.
I am the first generation in my family to attend college (neither my mother nor my father attended college).
English is not my primary language.

Referencing the table provided that defines status as economically disadvantaged based upon household income, please select “Yes” if the following statement applies to you or “No” if it does not apply to you:


My household income on the most recent federal income tax return was at or below the level listed.

Responses should be based upon your income or your parent's income if you are claimed as a dependent as reported on the most recent federal income tax return. Household income is considered relative to the number of persons in the family or household and the state of residence.

Persons in Family or Household48 Contiguous States and DCAlaskaHawaii
1 $23,760$29,680$27,340
2 $32,040$40,040$36,860
3 $40,320$50,400$46,380
4 $48,600$60,760$55,900
5 $56,880$71,120$65,420
6 $65,160$81,480$74,940
7 $73,460$91,840$84,460
8 $81,780$102,240$94,020
For each additional person add $8,320$10,500$9,560
My household income on the most recent federal income tax return was at or below the level listed.
Have you previously applied for admission to South College?
If Yes, when?
School or Program:
DO YOU WISH TO APPLY FOR FINANCIAL AID?
How did you learn about South College's Doctor of Physical Therapy program?
Are you currently employed by an Evidence in Motion (EIM) Network Partner, Clinical Excellence Network (CEN) Participant, or Advanced Program Graduate?
SECTION II: MILITARY EXPERIENCE
Are you currently serving on active or reserve duty in the U. S. Military?
Have you previously served on active or reserve duty it the U. S. Military?
If yes, with what branch(es) of service have you served?
If yes, how many years have you served?
Date or anticipated date of discharge?
Type of discharge?

SECTION III: SELF-REFLECTION ESSAY

In 300 words or less, tell us what sets you apart from the other applicants seeking admission to the South College DPT Program?

SECTION IV: APPLICANT SELF-ASSESSMENT OF READINESS FOR BLENDED LEARNING

The curriculum of the South College Doctor of Physical Therapy Program uses a blended learning model with delivery of the curriculum through a combination of online, onsite, and clinical learning environments. A number of personal qualities and life factors have been recognized as being relevant to the success of students participating in our accelerated DPT program.  Please rate each attribute as a personal strength or weakness with respect to your to past academic performance and your ability to be successful in this blended learning program.  Each attribute is rated on a scale of 1 – 5 (where 1 signifies a "personal weakness or concern", and 5 signifies a "personal strength or not a concern").

**NOTE: Please answer these questions honestly. Self-reflection is a critical behavior in clinical practice. Identifying potential areas that may be a personal "weakness or concern" is commended and DOES NOT reflect negatively upon you as an applicant!
Self-management (e.g. time management, organization of course materials and financial resources)
1
2
3
4
5
Availability of time to study
1
2
3
4
5
Persistence
1
2
3
4
5
Learning Skills (e.g. critical thinking, creativity, collaboration, communication)
1
2
3
4
5
Academic attributes (e.g., intelligence, reading comprehension, writing abilities)
1
2
3
4
5
Briefly discuss why these elements are or are not a concern. How would you address areas of concern to be successful in this program?

SECTION V: DISCLOSURE AND RELEASE STATEMENTS

CAPTE Accreditation Status Disclosure:

The Doctor of Physical Therapy program at South College is accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE), 1111 North Fairfax Street, Alexandria, Virginia 22314; telephone: 703-706-3245; email: accreditation@apta.org; website: http://www.capteonline.org.
I acknowledge that I have read and understand this statement regarding the program's Accreditation status.*

Please contact Dr. Mike Jones, School of Physical Therapy Director of Admissions, at mjones4@southcollegetn.edu if you have questions or concerns regarding program accreditation status.

Blended Learning Acknowledgement:

The South College DPT program is a blended learning program. As such, the DPT curriculum is delivered using a combination of online distance-based, on-site lab intensive, and clinical education course components. This means that applicants should be technically proficient in basic internet use, as well as able to travel to the on-site lab intensive sessions and clinical education experiences. By checking the box below, I acknowledge that I have read this statement, understand its implications, and agree to the aforementioned conditions.

Employment Acknowledgement:

Considering that the delivery of the curriculum of the program occurs through a blended-learning format, we recognize that some students may desire to maintain some level of employment while enrolled. However, the academic demands of this accelerated curriculum and the travel requirements for onsite lab immersions and clinical education will make employment virtually impossible for the majority of students. In fact, working more than a few hours per week would almost surely negatively affect your academic performance and is strongly discouraged. By checking the box below, I acknowledge that I have read this statement, understand its implications, and agree to the aforementioned conditions.
FERPA RELEASE
South College provides for the confidentiality of student records in accordance with the Family Educational Rights and Privacy Act (FERPA), as amended. I understand that in order to consider my application to the School of Physical Therapy, the Office of Admissions will release my student records as necessary to members of the School of Physical Therapy Admissions Committee, employees of South College and others who have a need to access my student records in order to process my application for admission.
Media Release

I hereby release South College and any firm with which South College may contract, from any debts, claims, actions, causes of action, demands, suits, and all liabilities whatsoever both in law and in equity, which may result from participation in any telecast or still photography made by or produced by South college.


In doing so, I hereby grant South College the right to use my name, photograph, likeness, or voice in any production connected with the College.

I hereby represent and warrant that I am of full age and have every right to contract in my own name in the above regard. I further state that I have read the above authorization and release prior to its execution and that I am fully familiar with the contents thereof. *
I certify that all statements made in this application are complete and true and understand that every student enrolling at South College agrees to abide by all policies and regulations of the College that may be found in the Student Handbook or in the College Catalog or other official publications. I understand and agree that any misrepresentation of facts on this application is just cause for refusal of admission or dismissal from South College. *

As acceptance of this registration, please type your full name below.

Applicant signature:*

By entering your name, the last four digits of your social security number, and submitting the document, you electronically agree and confirm your understanding of the items, as outlined, in the above document.

Please enter the last four digits of your social security number.

Last four of social:*
Word Verification: