Physical Therapist Assistant Program Application Your Name * Your VCCS ID * Street Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP * Phone * Your VCCS Email * Campus Selection * - Select -Locust GroveLuray I am a veteran planning on using VA benefits.* Yes No I attended a Germanna PTA Program information session in: Month Make selection here...JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year Make selection here...20202021202220232024 I have completed the following Volunteer or Observation hours and submitted the form to ptassistant@germanna.edu: Inpatient (not required) Yes No Outpatient (required) Yes No Please review the Essential Functions for the Physical Therapist Assistant Student document. I acknowledge that I have received and reviewed the above Essential Functions of the PTA Student, and understand that I am expected to meet all requirements with the exception of those noted on the attached documentation of accommodations, as agreed to by the PTA Department Program Director. Personal Statement essay (600-1000 words) * I certify that I am the author of this essay. Sign above CAPTCHA What code is in the image? Enter the characters shown in the image. Leave this field blank
