PTA Application: Middle Georgia State University

Physical Therapy Assistant Application

To apply for the Physical Therapy Assistant program complete the below form.

Required fields are marked with an asterisk

First Name*

Last Name*

Middle Name

MGA ID

Are you 18 years of age or older?*

Yes
No

Are you an international student?*

Yes
No

Preferred Email Address*

Mailing Address*

City*

State*

Zip Code*

Home/Cell Phone Number*

Emergency Contact

Contact Person*

Contact person phone number*

Education

A copy of all transcripts must be sent directly to the MGA Registrar. Please list all colleges/universities attended.

Complete Name of School

Attendance From (mo/yr)

Graduation Date (if applicable)

Degree Received or Hours Earned

Complete Name of School

Attendance From (mo/yr)

Graduation Date (if applicable)

Degree Received or Hours Earned

Complete Name of School

Attendance From (mo/yr)

Graduation Date (if applicable)

Degree Received or Hours Earned

Course Work

What is your cumulative GPA?*

Have you completed Anatomy and Physiology I & II with lab with a grade of C or better?*

Yes
No

Please provide your grades for any of the following courses you have completed:

(A “C” or better is required to be eligible for admission) Only one of the MATH courses listed are required.

ENGL 1101

ENGL 1102

MATH 1101

MATH 1113

PSYC 1101

PSYC 2103

HIST 2111 or 2112

POLS 1101

Literature elective

Academic History

Have you completed any other health or science degree programs?

Yes
No

If so, what degree?

What school?

Graduation date?

Have you had an unsuccessful attempt in any health science program in the past two years?*

Yes
No

Name of School

Which Program?

Last date attended (mo/yr)

Have you currently been accepted to Middle Georgia State University?*

Yes
No

TEAS Exam

Have you taken the Test of Essential Academic Skills (TEAS) and obtained a score of 58.7% or better?*

Yes
No

TEAS Score

Please be sure to have your TEAS score submitted to MGA’s PTA program.

Certifications

Do you hold any Certifications? (E.g. CNA, MA, EMT, personal trainer)

Volunteer Hours

Have you completed any volunteer hours at a Physical Therapy Clinic?

Yes
No

Name of Facility(ies)

Number of hours completed

Primary supervisor and contact (for verification)

Letters of Recommendation (Required)

Please submit two letters of recommendation from recent professors or recent/current employers (within the last year) to ptainfo@mga.edu.Letters of recommendation must come directly from the professor/employer and include both a professional email address and contact phone number.

Please provide your personal statement addressing the following questions (A minimum of 200 words is required):

Motivation: Why do you want to pursue a career as a Physical Therapist Assistant (PTA)?
Inspiration: What experiences or influences sparked your interest in the field of physical therapy?
Qualities: What personal qualities or characteristics do you believe are essential for success as a PTA, and how do you see those qualities reflected in yourself?

Motivation: Why do you want to pursue a career as a Physical Therapist Assistant (PTA)?*

Criminal Background Check and Drug Screening Policy

Students who enter the program must have a Criminal Background Check and Urine Drug Screen performed by a company approved by the Physical Therapist Assistant (PTA) Program. Clinical agencies will review the Criminal Background Check and Urine Drug Screen results. The student must be approved by the clinical agency to participate in clinical experiences and progress in the program.

Random Criminal Background Check or Urine Drug Screen may be required while in the PTA Program, based on the professional judgment of the faculty. This testing, if required, will be at the student’s expense.

Approval to admit applicants to the National Physical Therapy Examination (NPTE) or to grant a license rests with the Georgia State Board of Physical Therapy. Applicants who have ever been arrested, convicted, sentenced, pled guilty, or pled nolo contendere, or been given first-offender status for any felony, a crime involving moral turpitude, or a crime violating a federal law involving controlled substances or dangerous drugs, or a DUI or DWI, or who have been issued a license that has been encumbered (denied, revoked, suspended, surrendered, restricted, or placed on probation) by any state board, may take the NPTE only at the discretion of the Georgia State Board of Physical Therapy. Furthermore, the license may not be issued until the matter is resolved to the satisfaction of the Board.

Student Health Insurance

Students enrolled in PTA courses are required to have health insurance that meets minimum standards as mandated by the University System of Georgia. Students who are covered by an acceptable policy will have the opportunity to request a waiver.

Student Certification and Contact Information

Incorrect information or the omission of information that would have caused me to be ineligible may result in my application being denied. With this understanding, I certify that the above statements are complete and true.

Notify the Physical Therapist Assistant (PTA) Program of any change of address or phone number by contacting the Department of Rehabilitation Science and Fitness at ptainfo@mga.edu.

Developing PTA Program

Physical Therapy Assistant Application