DPT ATLANTA Supplemental Application

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DPT ATLANTA Supplemental Application

South College – Atlanta Campus
School of Physical Therapy

ATTN: DPT ADMISSIONS
2600 Century Pkwy NE
Atlanta, GA 30345

Biographical Information

Name:

Title:

First:

Last:

Middle:

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

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

Date of Birth:*

Preferred email address:*

Demographic Information (The following information is collected for institutional and program reporting purposes only. This data is sequestered and will not be available to the admissions committee during the application review or interview process. It has no bearing on admission decisions.)

Question 1: Ethnicity

Are you Hispanic or Latino?

Yes, Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

No, not Hispanic or Latino

I prefer not to respond / Unknown

Question 2: Race

Please select one or more races from the following list to describe yourself:

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America, and who maintains tribal affiliation or community attachment.)

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)

Black or African American (A person having origins in any of the black racial groups of Africa.)

Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)

I prefer not to respond / Unknown

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.

I am a licensed Physical Therapist Assistant.

I am a Certified Athletic Trainer.

I am currently serving, or previously served on active or reserve duty in the U.S. Military

Date or anticipated date of discharge:

Type of discharge:

None of these apply

Are you a former or current student of South College?

Yes

If yes, what was your major or what courses did you take?

Have you previously applied for admission to the South College DPT program?

Yes

Which South College campus have you applied, to or intend to apply to, for admission to the DPT program? (Select all that apply)*

Atlanta

Dallas

Knoxville

Nashville

Orlando

Why did you choose the campus(es) from above?

If the campus of choice has reached capacity, are you open to attending a different South College DPT program location? The South College School of Physical Therapy has five locations with varying cohort start dates: Atlanta (June), Dallas (June), Knoxville (June and January), Nashville (September), Orlando (September)

Yes

Maybe

If Yes or Maybe, which campus(es)?

Are you currently employed by Confluent Health?

Yes

Unsure

Are you currently employed by an Evidence in Motion (EIM) Network Partner, Clinical Excellence Network (CEN) Participant, or Advanced Program Graduate.

Yes

Unsure

Did you review South College DPT social media accounts (Instagram, Facebook, LinkedIn) to gain more information on our program before applying?*

Yes, I have followed one or more of these accounts.

Yes, but only minimally

I did not access these accounts

DISCLOSURE AND RELEASE STATEMENTS

CAPTE Accreditation Status Disclosure:

The Doctor of Physical Therapy program at South College Atlanta Campus is accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE), 3030 Potomac Ave., Suite 100, Alexandria, Virginia 22305-3085; telephone: 703-706-3245; email: accreditation@apta.org; website: http://www.capteonline.org. To file a complaint with CAPTE, contact them directly by phone or email. If needing to contact the program/institution directly, please call 470-322-2807 or email kshaw@south.edu

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

Yes

Please contact Lauren Johnson-Williams at lwilliams6@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 distanced-based, on-site lab intensive, and clinical education course components.

This means that applicants should be technically proficient in basic internet use, have access to reliable internet, as well as able to travel to the on-site lab intensive sessions and clinical education experiences.

By checking the box below, I acknoledge 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 employees of South College who have a need to access my student records in order to process my application for admission.

Yes

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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