Pysical Therapy Assistant Program Online Application

Louisiana Christian University School of Allied Health

APPLICATION AND ESSENTIAL REQUIREMENTS FORM

BIOGRAPHIC INFORMATION:

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    xxx-xx-
    Please enter a number from 4 to 4.
    Mailing Address:
    Permanent Address:

    **If you will be moving prior to summer 2022 please provide an updated mailing address and telephone contact number that can be used. Your permanent address will be used as the default address.

    MM slash DD slash YYYY
    Place of Birth:
    Gender
    Ethnic Origin

    EDUCATIONAL INFORMATION:

    List in chronological order (most recently attended first) every college and university you have attended or will be attending prior to entering the Louisiana College Allied Health Program. official transcripts must be provided from each institution listed.
    1
    2
    3
    4

    WORK HISTORY

    List in chronological order previous work history in Physical Therapy Clinics (most recently employed first).
    1
    2
    3

    SCHEDULED COURSES – SPRING 2022

    Are you currently enrolled in or plan to enroll in courses for the Spring 2022 semester If yes, please complete the chart below.
    Example: ABC University
    COLLEGE/UNIVERSITY
    EN
    DEPARTMENT CODE
    101
    COURSE NUMBER
    Composition
    TITLE
    3
    CREDIT HOURS