DPT Nashville Supplemental Application

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DPT Nashville Supplemental Application

South College - Nashville Campus
School of Physical Therapy
ATTN: DPT ADMISSIONS

616 Marriott Drive

Nashville, TN 37214

SECTION I: BIOGRAPHICAL INFORMATION

Name:

Title:

First:

Last:

Middle:

Under what other name(s) might documents be received?

Marital Status

Single

Married

Separated

Divorced

Widowed

Age:*

Date of Birth:*

Place of Birth:*

Race:*

Social Security Number:*

Sex:*

Telephone number at which you can be reached between 8:00am and 6:00pm ET:

Home Phone:

Cell Phone:

E-mail:

Permanent Address:

Street Address:

City:

State / Province / Region:

Postal/ Zip Code:

Country:

Temporary Address:

Street Address:

City:

State / Province / Region:

Postal/ Zip Code:

Country:

Preferred mailing address:

Permanent

Temporary

County and state of legal residence:

County:

State:

Employed by:

Occupation:

Business Phone:

Emergency Contact Name:

First:

Last:

Relationship:

Emergency Contact Address:

Street Address:

City:

State / Province / Region:

Postal/ Zip Code:

Country:

Emergency Contact Phone:

Are you a United States Citizen?

Yes

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

Please select the racial and/or ethnic category with which you most closely identify.

American Indian or Alaska Native

Asian

Black or African-American

Hispanic/Latino

Native Hawaiian or Other Pacific Islander

White or Caucasian

Self Describe (Please use box below)

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

Urban (>1,000,000 population)

Large city (100,000 to 1,000,000 population)

Mid-size city (50,000 to 99,999 population)

Large town (10,000 to 49,999 population)

Small town (2,500 to 9,999 population)

Isolated rural (<2,500 population)

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 participated in an academic enrichment program funded in whole or in part by the Health Careers Opportunity Program, TRiO, or Upward Bound.

I am the first generation in my family to attend college (neither my mother nor my father attended college).

I applied or plan to apply for the PTCAS application fee waiver or assistance program.

I am fluent in 2 or more languages.

English is not my primary language.

I am/will be a graduate of a minority-serving institution or HBCU.

None of these apply

Have you previously applied for admission to South College?

Yes

Have you applied (or do you plan to apply) to another South College DPT program this school year?

Yes

If Yes, which campus?

Do you wish to apply for Financial Aid?

Yes

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?

Yes

Unsure

SECTION II: ADDITIONAL EXPERIENCE

Are you a licensed Physical Therapist Assistant?

Yes

Do you hold an Athletic Training Certificate?

Yes

Are you currently serving on active or reserve duty in the U.S. Military?

Yes

Have you previously served on active or reserve duty in the U.S. Military?

Yes

Date or anticipated date of discharge?

Type of discharge?

SECTION III: 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 order each of the following attributes or skills in order of highest personal strength to relatively lowest personal strength. You will place a # between 1 and 8 to order with 1 being your strongest characteristic.

**NOTE: We recognize you may be strong in all of these attributes but we want you to place in order with strongest as #1. Please answer these questions honestly and only use each number once. Self-reflection is a critical behavior in clinical practice.

Time Management

Financial Resources

Self-Starter (motivated)

Creativity

Communication

Reading Comprehension

Writing Abilities

Determination

If accepted to this DPT program, realistically, how many hours per week do you have available to study?

1-10 hours

11-15 hours

16-20 hours

21-25 hours

26-30 hours

>30 hours

Please share any additional information about yourself or your journey that you would like us to know about you. This could be anything
that might help us support you throughout the program.

SECTION IV: DISCLOSURE AND RELEASE STATEMENTS

CAPTE Accreditation Status Disclosure:

Graduation from a physical therapist education program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE), 3030 Potomac Ave., Suite 100, Alexandria, Virginia 22305-3085; phone; 703-706-3245; accreditation@apta.org is necessary for eligibility to sit for the licensure examination, which is required in all states. Candidacy is considered to be an accredited status, as such the credits and degree earned from a program with Candidacy status are considered, by CAPTE, to be from an accredited program. Therefore, students in the charter (first) class should be eligible to take the licensure exam even if CAPTE withholds accreditation at the end of the candidacy period. That said, it is up to each state licensing agency, not CAPTE, to determine who is eligible for licensure. Information on licensing requirements should be directed to the Federation of State Boards of Physical Therapy (FSBPT;www.fsbpt.org) or specific state boards (a list of state boards and contact information is available on FSBPT's website.

South College- Nashville is seeking accreditation of a new physical therapist education program from CAPTE. The program is planning to submit an Application for Candidacy, which is the formal application required in the pre-accreditation stage, on December 1, 2023. Submission of this document does not assure that the program will be granted Candidate for Accreditation status. Achievement of Candidate for Accreditation status is required prior to implementation of the professional phase of the program; therefore, no students may be enrolled in [professional/technical] courses until Candidate for Accreditation status has been achieved. Further, though achievement of Candidate for Accreditation status signifies satisfactory progress toward accreditation, it does not assure that the program will be granted accreditation.

IMPLICATIONS OF SEPTEMBER GRADUATION The developing physical therapy program at South College - Nashville is planning for a charter class graduation in September, 2026. Initial accreditation decisions are acted upon at the next regularly scheduled Fall Meeting of the Commission following the on-site visit, which must occur during the penultimate term when the charter class is enrolled. CAPTE will not make exceptions to its Rules to accommodate graduation dates that precede regularly scheduled CAPTE meeting dates, e.g., graduation in the summer. A summer graduation does not allow the initial accreditation decision to occur prior to the graduation date. The Federation of State Boards of Physical Therapy (FSBPT) sets the dates for licensing exams. The first sitting for which students with a September graduation date would be in January. Therefore, the timing of the planned graduation date increases the likelihood of a significant financial disadvantage for students due to an approximate six-month delay in possible employment as a physical therapist.

I acknowledge that I have read and understand this statement regarding the program's Accreditation status.

Yes

Please contact Jessica Maxwell, School of Physical Therapy, at jmaxwell1@south.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.

Yes

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.

Yes

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.

Yes

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.

Yes

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.

Yes

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

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 as well as authorize the payment of the Supplemental Application fee to South College.

Supplemental Payment ($60.00):

Full Name:

Last four of social:

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