Physical Therapist Assistant Program Application If you are human, leave this field blank.Personal InformationSemester *Fall SpringYear *2019202020212022First Name *Middle Name *Last Name *MaidenStudent ID *BirthdayAddress *CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip code County of ResidenceWyandotteLeavenworthPhone *Email *Program contact is made through email. Please ensure you accept emails from mavery@kckcc.edu and that you check your emails regularly. Colleges AttendedList all colleges and universities attended, including KCKCC, beginning with most recent. Please request each college forward two (2) official transcripts, one to the college registrar and one to the PTA program. Your application is not complete until transcripts are received. Transcripts from KCKCC will be requested by the PTA Program Coordinator.Name of SchoolLocationDates of AttendanceName of SchoolLocationDates of AttendanceDegrees EarnedAssociate DegreeBachelor DegreeMaster DegreeDoctoral DegreeCheck all that ApplyCurrently enrolled at KCKCCPreviously enrolled at KCKCCKCKCC application submittedCurrently enrolled at another collegeCourse RequirementsHUDV 100/01 Strategies/Orientation**Semester / YearCollegeGrade BIOL 0143 - Anatomy and Physiology**Semester / YearCollegeGrade PSYC 0101 - Introduction to Psychology**Semester / YearCollegeGradeMATH 0104 - Intermediate Algebra**Semester / YearCollegeGrade ENGL 0101 - Composition 1**Semester / YearCollegeGrade SPCH 0151/53 - Public Speaking / Interpersonal CommunicationsSemester / YearCollegeGradeCollegeGrade PSYC 0101/03 - Child or Human DevelopmentSemester / YearCollegeGradeInstructions Please complete the following information about the for hours observation you completed. Additionally, please submit a reflection paperĀ pta@kckcc.eduĀ outlining how your observation experience confirmed your desire to enter the field of physical therapy and what skills you possess that would be of benefit to a physical therapy department. Name of FacilityDateHours *Brochure *By selecting an option, I indicate that I have read the program brochure in its entirety. I certify that I understand the physical and mental requirements of the program and the profession and am able to perform these skills (with reasonable accommodations, if applicable). Furthermore, I certify that all information on this application is correct and complete. False information could result in dismissal from the program. NoYesTech / Aide Exemption *In lieu of completing the observation hours, I have been a tech/aide in a physical therapy setting for at least 150 hrs and will be submitting proof of hours and letter of recommendation from a supervising PT/PTA. I will still submit a reflection paper related to my experiences. NoYesInstructionsIf you have a documented disability that requires accommodations for the interview assessment, you must contact the Student Accessibility and Support Services at 913-288-7664. It is recommended that this process be started 6 weeks prior to the application deadline. Have you received the PTA Program Information brochure? *NoYesSignature *Date *Submit