SPRING 2014 APPLICATION: 
OCCUPATIONAL THERAPY ASSISTANT PROGRAM

Please note: This application is only valid for the Spring 2014 semester in which there are 8 spots, and 4 alternate positions, available. Submitting this application does not guarantee acceptance into the OTA program for Spring 2014 or future semesters. If students are not randomly selected to participate in the Spring 2014 semester they will need to re-apply during the Spring/Fall 2015 application filing period that will take place June 16, 2014-September 15, 2014.

SECTION I: Format

□ SPRING (On Campus/Daytime) 

SECTION II: General Information

Name _____________________________________________________________________________________
			Last				First					Middle

Student ID# ______________________________		Email Address ______________________________

Address ___________________________________________________________________________________
			Street			City			State			Zip Code

Cell Phone _______________________________		Home Phone _______________________________

Emergency Contact __________________________________________________________________________
				Name			Relationship			          Phone Number

Email is the OTA Program’s primary method of contact. Therefore, I understand that it is my responsibility to keep my home and email address, as well as my phone number, current with the Admissions and OTA office so as to not jeopardize my status on the list.	Initial _____________		Date _______________

SECTION III: Background Information (verified by official transcripts)

High School 	□ Diploma ___________	or	□ GED ___________
				  Year				        Year

College/University __________________________     AA/AS ______________________		Year _______
									             Major

College/University __________________________     BA/BS ______________________		Year _______
									             Major

Level III Math Placement Score ____________ Test Date ______________ (must be completed before February 3, 2014)

•	Or Math Course ________________________________________________________________	
                Course Name                     Grade                Units                                      College

SECTION IV: Prerequisites (verified by official transcripts)

Office Review	Prerequisites
(or equivalent) 	College	Course Name	Course Number	Units	Grade	
	*English 101 
						
	*Communication Studies 
(101, 102, 140, 145, or 152)
						
	*Anatomy & Physiology or Anatomy (separately) and Physiology (separately)
						
	*Psychology 100

I understand that I am responsible for completing the general education requirements for the AS degree prior to starting the fourth, and final semester, of the OTA program. A list of general education requirements can be found in the college catalog; however, it is recommended that you make an appointment with the Counseling Center to review that you have met these requirements.	Initial ____________	Date _______________

SECTION V: Certification of Information
I certify that all information provided on this application is true and accurate. I have also included official transcripts that certify my completion of the prerequisite courses. I understand that if accepted into the OTA program I will need to provide evidence of a physical examination and appropriate immunizations verifying my physical ability to perform the clinical requirement of the OTA.

Student Signature _________________________________________		Date ________________