MTC PTA Program Application for Class of 2024

*****Must fill in all fields or the form will not submit*****

Applicant’s Name:

Applicant’s Date of Birth:
Previous/Maiden Name(s): Only a required field if you have a maiden name.

Submit this application ONLY if you can answer YES to each of the following questions.

I have submitted the following general admission requirements to the MTC Office of Admission:

      • √ MTC General Application for Admission (Indicate PTA as your Major/Program on the application)
      • √ $20 general MTC application for admission fee (if not already an MTC student)
      • √ Official high school transcript and/or GED score results
      • √ Official college transcript(s) from other colleges attended (if applicable; please list all Colleges that you have requested send transcripts to MTC at the end of the application).

I have completed high school or college coursework reflecting a 2.5 (on a 4.0 scale) overall grade point average (GPA).

(GPA for fewer than 12 college semester or quarter hours at one institution will not be considered).

Note to high school seniors:

You must be 18 years of age before taking PTA classes (with the exception of PTA 1000).  Please use grades as of the end of seventh semester, senior year. *If your High School GPA is not on a 4.0 scale, please request it be converted to a 4.0 scale before the transcript is sent to MTC.

My qualifying GPA is from: (Name of High School or College)

I have completed high school statistics or algebra and received a grade of C or higher, MTH0910 {Mathematical Literacy}, or equivalent placement).
I successfully completed statistics/algebra at: (Name of High School or College)
I have completed high school or college chemistry and high school or college biology and received a grade of C or higher in each (or completion of SCI 1050 {Principles of Biology & Chemistry} or equivalent).
I successfully completed biology at: (Name of High School or College)
I successfully completed chemistry at: (Name of High School or College)

 Yes:  I have completed the 40 observation hours minimum and have asked TWO licensed PTs or PTAs to submit an Observation Verification/ Recommendation directly to MTC at
I completed (Number of hours) at (Name of facility)

I completed (Number of hours) at (Name of facility)

Yes:  I have completed 5 (FIVE) Video Reflection Assignments with minimum grade of 90% in the PTA Admissions online webpage.
I have read all the information contained in the Physical Therapist Assistant program admission packet. I understand the requirements and demands of this program.
I understand that if I am offered a seat in the PTA Program, I must complete a successful criminal background check before being admitted into the program and must complete a successful drug screen before entering into the clinical component of the program.
I wish to begin the PTA Program technical course sequence fall semester.
All of the above information MUST be completed in order to be considered for admission to the PTA program.

Evidence of the following items may improve an applicant’s chances for admission.

Please check these items only if they are included with this application or if they are being sent directly to MTC:
I have opted to submit my official ACT scores.
ACT test date: (exact date not required) ACT Composite Score:

OR, I have a completed Bachelor’s Degree from:
OR, I have a completed Master’s Degree from:

I have a current nationally recognized certification/license in health/allied health. ( LMT, CSCS, CPT STNA, etc)
(please provide photocopy of license/certification)
Please note that my college transcript(s) reflect completion of one or more of the following courses, or a transfer equivalent, with a grade of C or better.
• SCI 1200 Anatomy and Physiology I completed at: (Name of College)
• SCI 1250 Anatomy and Physiology II completed at: (Name of College)
• MTH 1240 Statistics completed at: (Name of College)
Optional: I have completed PTA 1000 Introduction to Physical Therapy at MTC with a grade of “B” or higher.
Submit this application and accompanying materials to the PTA Program at MTC by March 1, 2022.

All materials MUST be received by the PTA Program by the March 1 application deadline.

The PTA Program reserves the right to extend this deadline or admit qualified candidates, on a first come-first served basis in the unlikely event that the class is not filled by the March 1, 2022 application deadline.

Applicants receiving this information later than March 1, 2022 are advised to contact the PTA office to learn if seats in the program remain available.

To the best of my knowledge, the information that I provided on this application form is truthful and accurate.
Applicant’s Signature: Date:

MTC Student ID. or Date of Birth:
Applicant’s Address:

Applicant’s Phone:
Applicant’s Date of Birth:
Applicant’s e-mail address:
For information regarding the status of your application and to confirm receipt of materials, you must email
**Additional Observation Hours completed:
I completed: (List number of hours) at: (Name the facility)
***A College transcript has been requested from the following College(s) and should be received by the PTA Program by March 1 Deadline (List all Colleges):

Agreement to Respect Confidentiality, Privacy, and Security

Maintaining confidentiality, privacy, and security is a key principle in today's health care setting. The purpose is to promote trust in professional relationships between patient/family members and individuals working in the health care environment, facilitate truthful and complete disclosure of information by patients, and protect patients, health care providers, and health care facilities from harm by preventing disclosure of information. Some information may be harmful to an individual's reputation, personal relationships or employment.

Confidentiality carries the responsibility for limiting disclosure of private matters. It includes the responsibility to use, disclose, or release such information only with the knowledge and consent of the individual. Privacy is the right of an individual to be left alone. It includes freedom from observation or intrusion into one’s private affairs and the right to maintain control over certain personal and health information. Security includes physical and electronic protection of the integrity, availability, and confidentiality of computer-based information and the resources used to enter, store, process, and communicate it; and the means to control access and protect information from accidental or intentional disclosure.

Confidential information includes but is not limited to: patient information, medical records, hospital/medical office information, pharmacy, physician information, employee records, and any situation which may be encountered in the course of your clinical/practicum experience and on campus.

Maintaining confidentiality means to share information only with other healthcare professionals who have a “need to know” the information to provide proper healthcare for that patient and/or to conduct business within the health care setting. Obtaining and sharing information in which there is not a “need to know” is a violation of confidentiality. Sharing any information about your clinical practicum site or staff is a breach of confidentiality.

Information that is a benefit to the learning experience may be shared with an instructor or other students as part of a classroom assignment. Information must exclude patient identifiers/confidential information. As part of a learning experience, this would be considered a legitimate “need to know”. Sharing this information outside of class is a breach of confidentiality.

A common way in which information is shared unnecessarily is through casual conversation. Sometimes a patient or a situation is very interesting and information is shared with one's own family, friends, or co-workers who are not involved with that patient. Simply mentioning that you saw an individual in a healthcare setting is considered a breach of confidentiality. Other times, information is shared inadvertently. Two employees, both needing to know information about a patient, discuss the case in the elevator or in the cafeteria, and a visitor overhears the information. This illustrates why it is imperative to limit clinical discussions to non-public areas.

Records such as any part of a patient's chart are not to be read by individuals other than those having a “need to know”. Retrieving information from a computer also falls into this category. A "need to know" refers specifically to work needs. Looking up lab results for a friend or a family member is not acceptable "need to know". Friends and family need to find out their lab data from the physician who ordered it.

Agreement requiring applicant/student signature:
I, have read the above information regarding confidentiality, privacy, and security and I understand the importance of keeping all information I encounter during observation or a professional practice experience in confidence.

    • I agree to maintain confidentiality in the healthcare site and will not divulge any healthcare information outside the healthcare site.
    • I will not access or try to access patient or healthcare information without the approval of the professional practice site and my instructor/preceptor.
    • I understand that cell phones are not permitted during observations or a professional practice experience.
    • I will not remove records, papers, medications or specimens from the healthcare site without permission.
    • I will not take notes of any confidential information and remove it from the healthcare site.
    • I agree that I will not take pictures of patients or of confidential information.
    • I agree to use caution when discussing confidential matters in the healthcare site to avoid being overheard in any public area.
    • I understand that violating this policy may prohibit me from admission to any MTC health technologies program, or result in my removal from the professional practice, a failing grade, and dismissal from the program.
    • I will continue to maintain confidentiality, privacy, and security with any information I encounter during my learning experience after I have completed my courses at Marion Technical College.

MTC Student ID or Date of Birth:
C/D: Confidentiality Agreement 6.25.12

Signature (Type your name)