Fill - Free fillable Physical Therapist Assistant Program Application (Anne Arundel Community College) PDF form

Physical Therapist Assistant

Program Application

Applications Available: November 16, 2020

Application Deadline: March 30, 2021

Program Start: Fall, 2021

ADMISSION REQUIREMENTS

To become a candidate for selection to the Physical Therapist Assistant Program, please complete and return the

attached application by email to vbardhi@aacc.edu or mail application to:

Anne Arundel Community College

ATTN: School of Health Sciences, FLRS 112

101 College Parkway

Arnold, MD 21012



Attend an Information Session. Please visit http://www.aacc.edu/cache/pta for dates and times. Admission and

selection information will be reviewed. Virtual information sessions will be considered face-to-face.



Submit official transcripts, if applicable. Official transcripts are to be received by AACC Records and Registration

office in the sending institution’s original sealed envelope or through acceptable electronic method; visit

https://www.aacc.edu/apply-and-register/credit-application/apply/transfer-credit-to-aacc/ for details. Transcripts

must be on file in the Records Office prior to making application or attached to the application at time of

submission.



Submit an official high school transcript or GED equivalency transcript and college transcripts (if applicable) by

May 1, 2021. Current high school seniors must submit official high school transcripts by June 15, 2021.



Demonstrate eligibility for ENG 101/ENG 101A.



Demonstrate 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 selection.



Must have a minimum adjusted grade point average (GPA) of 2.0 at this college.



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 selection.

Following review of applications, students will receive an email sent to their AACC email account regarding the

status of their application.

IMPORTANT INFORMATION



A mandatory, virtual meeting will be held on Wednesday, April 28, 2021, from 3:00 p.m. to 5:00 p.m. for all

applicants. 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 2021 class must attend this meeting and remain for the entire meeting. Students who are

unable to attend this meeting must email the Health Sciences Admissions Assistant, Valerie Bardhi at

vbardhi@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 Valerie Bardhi via email at: vbardhi@aacc.edu. Any applicant

having a change of mailing address, email address, or telephone number during the application process must notify the

Admissions Office by email at vbardhi@aacc.edu.

For selection, qualified applicants will be classified in one of the following categories:

Conditional Acceptance: Applicants who have met the academic and admission requirements and have

been selected into the program are given conditional acceptance. Students who are granted conditional

acceptance must submit a criminal background check, health examination record and current American

Heart Association Basic Life Support (BLS) CPR certification by designated deadlines. Those who do not

meet these deadlines will not be further considered for admission.

Wait List: In the event there are more qualified applicants than seats available, qualified applicants not

initially selected for conditional acceptance will be placed on a list in rank order and notified for selection

when a seat becomes available. If applicant declines the seat, they will need to reapply for a future seat

in the program.

Final Acceptance: Applicants who have been selected conditionally and have submitted complete health

examination records, submitted a satisfactory criminal background check, and verification of a valid

American Heart Association BLS CPR certification.

This program is competitive and seats are limited; therefore, not all qualified candidates will be selected.

IMPORTANT INFORMATION

All health sciences students who are offered admission and/or clinical placement will be required to submit 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 and of a urine drug

screen.*

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 are 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.

* Notwithstanding 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 2020-2021 IC Approved FINAL\Word copies\PTA Application 2021_IC

Approved.10.27.2020.docx

CHESAPEAKE AREA CONSORTIUM FOR HIGHER EDUCATION

Anne Arundel Community College * Chesapeake College * College of Southern Maryland

PHYSICAL THERAPIST ASSISTANT

FALL 2021

Application Deadline – March 30, 2021

Program Application

Submit completed application to vbardhi@aacc.edu or via mail to Anne Arundel Community College, ATTN: School of

Health Sciences, FLRS 112, 101 College Parkway, Arnold, MD 21012.

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 on this application will be your address of record. It is your responsibility to notify the

Health Sciences Office as well as the Records Office of name, address and phone number changes during the application

process. Applicants are advised to check their AACC email account periodically for placement updates and notices.

Home Phone

Cell Phone

Work Phone

AACC Email Address – Required

No other email is acceptable

@mymail.aacc.edu

Admission/Academic Requirement Checklist

By signing below, I agree/understand the following:

I have an active admission status at AACC and am in Good Standing (2.0 GPA>) with the college.

All academic admission requirements, including prerequisites, must be completed by the end of the spring 2021

semester. Pass/Fail grades are not acceptable.

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, WES or SpanTran to verify/authenticate your high

school and/or college transcripts by the stipulated by the end of the spring 2021 semester.

I have submitted the Address Verification Form with this application including two supporting documents.

If information is incomplete/missing from my application or file, it will NOT be processed and will be returned to

me.

I understand that by filling in my name below, it will be considered my signature.

SIGNATURE: DATE:

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signature

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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 (3-4 credits)

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 or through acceptable electronic method.

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:

INTERNATIONAL STUDENTS

TOEFL EXAM (If applicable)

(Native Language NOT English)

Semester/Year: Score/Grade Where Completed:

TRANSCRIPTS

Have you submitted an official transcript evaluation report from ECE, WES, or SpanTran to verify/authenticate your high

school and/or college transcripts to the Records office prior to or with your program application?

Yes 

No 

AGENCY USED:

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(s) of the institution(s) you are submitting a transcript(s) from on the line below:

* Official transcripts are to be received by AACC Records and Registration office in the sending institution’s original sealed

envelope or through acceptable electronic method, visit https://www.aacc.edu/apply-and-register/credit-

application/apply/transfer-credit-to-aacc/ for details.

A mandatory virtual meeting for all applicants is scheduled on Wednesday, April 28,

2021 from 3:00 pm to 5:00 pm. All students seeking admission to the fall 2021 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 2021 PTA program. It is your responsibility to check your

AACC email account for notifications from the Health Sciences Admissions Office.

GENERAL EDUCATION COURSES

Must be completed with a grade of C or better

Due to the selection process, the Physical Therapist Assistant program cannot accept

Pass/Fail as a replacement for letter grades in the required courses.

LAST NAME:

FIRST

NAME:

COURSE

GRADE

CREDITS

COLLEGE WHERE

COMPLETED

TERM AND

YEAR

COMPLETED

BIO 231 Human Biology 1

and

BIO 232 Human Biology 2

BIO 233 Anatomy and

Physiology 1

and

BIO 234 Anatomy and

Physiology 2

ENG 101/ENG 101A

Academic Writing and Research 1

(Previous ENG 111 or ENG 121 will be accepted)

PSY 111

Introduction to Psychology

PSY 211

Developmental Psychology

MAT 137 College Algebra

Previous MAT 121, 131, 141, 142, 145, 151, 191

or 230 will be accepted. No other math is

acceptable for this program.

Arts/Humanities Elective

(Gen Ed Requirement from catalog)

List Course:

Note: It is your responsibility to indicate any courses listed above that you are currently enrolled in during the

spring 2021 term. You may not receive points for courses you do not disclose on this application.

BACKGROUND INFORMATION

Submit explanation of questions for which you answer "yes" and provide documents relating to your answer in a sealed

envelope and emailed to tdneall@aacc.edu or mailed separately to address on first page of this application, ATTN:

Tammie Neall.

Yes







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.

Yes









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.

Yes









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.

Yes





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.

Yes









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.

Yes









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.

I understand that by filling in my name below, it will be considered my signature.

Signature: Date:

PRINT NAME:

Please review prior to submitting this application. This application must be completed in its entirety.

click to sign

signature

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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.

Be certain to include two (2) forms of supporting documentation as stipulated on the form.

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 or

mamumma@aacc.edu.

Out-of-county/state applicants will be reviewed only when space is available.

September 2020

Notice of Nondiscrimination: 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.

OFFICE USE ONLY

Program: PTA

Verify Term: SP21

101 College Parkway, Arnold, Maryland 21012-1895 410-777-2243

ADDRESS VERIFICATION FOR HEALTH SCIENCE PROGRAM APPLICANTS

Directions: This form must be completed entirely and supporting documents submitted as part of the health sciences

program application process. Applications submitted without this document will be returned as incomplete.

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.

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.

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 addresses 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 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 including 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

Student Name

Student ID or SSN (last 4 digits)

Resident Address

City

State

Zip

County

Day Phone

Evening

Dates of Occupancy at above address

 Own

 Rent

Previous Address

City

State

Zip

How long did you live at this previous address?

Are you registered to vote?  Yes  No

County

State

Do you possess a valid driver’s license?  Yes  No

If yes, what state issued?

County

Date of Issuance

Do you own a motor vehicle?  Yes  No

If yes, in what state issued?

County

Date of Issuance

Do you have the use of another person’s motor vehicle?  Yes  No

If yes, provide name

Relationship to student

Are you paying Maryland income tax for this year on all earned income?  Yes

 No

If yes, what county?

List where you have filed tax returns for the past two (2) years:

Year State County

If employed, is Maryland income tax currently being withheld?  Yes  No

If yes, what county?

For the most recent 12 months, has another person(s) provided one-half or more of your financial support?

 *Yes  No

*If the answer to the above question is “Yes”, SECTION B of this form must be completed by your supporter.

Additional Information

The college reserves the right to request additional information and documentation as necessary.

I CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS CORRECT TO THE BEST OF MY KNOWLEDGE.

Signature of Student (required) Date

OFFICE USE ONLY

ACCEPTABLE DOCUMENTS:  MILITARY/BRAC WAIVER:

____ MD driver’s license ____ Military ID (& Dependent ID if spouse or dependent)

____ MD income tax return (not U.S.) ____ Copy of Orders

____ Voter Registration Card ____ Copy of housing assignment, lease, deed or utility bill

____ Vehicle registration showing resident address

____ Utility bill showing home address

____ Copy of deed of trust or signed lease

____ MD withholding form – MW 507 (not U.S. W-2)

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 YOU ANSWERED “YES” to the following question:

For the most recent 12 months, has another person(s) provided one-half or more of your financial support?

Name of supporter

Relationship to student

Supporters Address

City

State

Zip

County

Day Phone

Evening

Date of Occupancy at above address

 Own

 Rent

Previous Address

City

State

Zip

How long did you live at this previous address?

Are you registered to vote?  Yes

 No

County

Do you possess a valid driver’s license?  Yes

 No

If yes, in what state issued?

County

Date of Issuance

Do you own a motor vehicle?  Yes

 No

If yes, in what state issued?

County

Date of Issuance

Do you have the use of another person’s motor vehicle?  Yes  No

If yes, provide name

Relationship to student

Are you paying Maryland Income tax for this year on all earned income?  Yes  No

If yes, which county?

List where you have filed tax returns for the past two (2) years:

Year State County

If employed, is Maryland income tax currently being withheld? 

Yes

 No

If yes, in which county?

Additional information:

The college reserves the right to request additional information and documentation as necessary.

Signature of supporter:

Date:

Notice of Nondiscrimination:

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.

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