Occupational Therapy Assistant and
Rehabilitation Program Applications

 

 

Directions
1. Fill out the following form. Note: Required fields are marked by a *.
2. Click on either the "E-mail Application" button or the "Print Application" button. Clicking on the "E-mail Application" button will e-mail your application to Occupational Therapy Department. Clicking on the "Print Application" button will display a page to be printed and mailed to the Occupational Therapy Department (Address is on the print out).

Name:*  
Social Security Number:*   
Current Mailing Address:*
Street/PO Box
City, State Zip


Permanent Mailing Address:*
Street/PO Box
City, State Zip


Home Phone:         
Work Phone:         
Permanent Phone:  

Compass score for reading:       
Compass score for writing:        
(Supporting documentation required)
Note: Compass scores not required if you have completed English 101 with a C or better. (Supporting documentation of transcript from an accredited university required.)

Have you attended any college or university: *    Yes No
If you answered yes to the previous question, list all collages of university you have attended. (Transcripts required)

Institute:                 
Attended:                January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 to January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Number of credit hours completed:    
GPA:                     

Institute:                 
Attended:                January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 to January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Number of credit hours completed:    
GPA:                     

Institute:                 
Attended:                January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 to January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Number of credit hours completed:    
GPA:                     

Institute:                 
Attended:                January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 to January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Number of credit hours completed:    
GPA:                     

Prerequisites - List course, grade received and date of completion and school where class was taken. (Transcript from appropriate school required.)


Biology *
Course:   
Grade:    
Year:       <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
School:   

Algebra *
Course:   
Grade:    
Year:       <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
School:   


Experience (Resume may be substituted for this section)


Work Experience you may attach additional if needed

Employer:                       
City/State:                       
Position/Duties:               
Dates of Employment:      January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 to January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005


Employer:                       
City/State:                       
Position/Duties:               
Dates of Employment:      January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 to January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Employer:                      
City/State:                      
Position/Duties:              
Dates of Employment:     January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 to January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Employer:                      
City/State:                      
Position/Duties:              
Dates of Employment:     January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 to January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Employer:                      
City/State:                      
Position/Duties:              
Dates of Employment:     January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 to January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005


Volunteer Experience:

Facility:                          
Area of service:              
Duties:                            
Dates of service:              January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 to January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Facility:                           
Area of service:               
Duties:                             
Dates of service:               January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 to January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Facility:                           
Area of service:               
Duties:                             
Dates of service:               January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 to January February March April May June July August September October November December <1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005



References:
List 3 professional references we may call. Be sure phone numbers are current. If we are unable to contact these persons due to inacurate information, points for your application will not be accrued.

Name:*             
Telephone:*        
Relationship:*    
Years known:*  

Name: *            
Telephone:*      
Relationship:*    
Years known:*  

Name:*             
Telephone:*      
Relationship:*    
Years known:*  

Short Essay - Please write essays in response to the following topic/questions on a separate sheet of paper. Submit essays with application.

1. Please describe any experience you have working with, spending time with, or living with individuals with disabilities. If you have no experience, summarize your thoughts on what it might be like to actually have and live with a disability.

2. In choosing a career, how and why did you choose occupational therapy?