1. health and fitness
2. therapy
3. physical therapy

Physical Therapist Assistant Application
Rogue Community College
Rogue Community College (RCC) has developed a partnership with Lane Community College (LCC) to provide
training for Physical Therapist Assistants in Jackson and Josephine counties. This program offering has obtained
approval by the Commission on Accreditation in Physical Therapist Education (CAPTE) as a distance cohort of the LCC
PTA Program. This program will prepare students to function as competent entry-level Physical Therapy Assistants in
a variety of practice settings and to pass the National Physical Therapist Assistant Examination (NPTAE) administered
by the Federation of State Boards of Physical Therapy.
This program will provide an Associate of Applied Science degree awarded by Lane Community College, with
RCC offering program prerequisites, general education, and related coursework. Financial Aid is accomplished
through the LCC Financial Aid office using an Individual Consortium Agreement between RCC and LCC. Contact the
LCC Financial Aid office for details.
A maximum of up to 10 students move through the LCC program as a distant site cohort. Students use a
distance education (DE) model of accessing the Physical Therapist Assistant (PTA) program-specific courses through
LaneOnline. The entire program can be completed while a student is living in the local area (Jackson and Josephine
counties) with a combination of RCC classes and the LCC distance education events. The curriculum includes
classroom, laboratory, and clinical components. The program is designed to be completed within two years and
students must fulfill all requirements within five years of admission into the program. Clinical placements are
determined by the LCC Academic Clinical Coordinator and will depend on availability of sites. Students may have to
travel out of their immediate geographic area to a location in the Pacific Northwest.
Important Program Dates:
Classes begin Fall Term 2015 and continue through Spring Term 2017
Application Dates:
We will begin accepting applications May 25th, 2015
Applications must be submitted by June 19th, 2015 at 5:00 pm
See page 2 for information regarding the online application
questionnaire and submitting supplemental materials.
Interviews:
Students who score highest in the application process will be invited for
an interview (12-20). Interviews will be conducted June 29 – July 2,
2015.
Admission Decision:
Students will be notified via email the week of July 6th, 2015 regarding
acceptance into the program.
Mandatory Orientation:
Admitted students will receive information on the day, time, and
location of this orientation to be held at RCC’s Table Rock Campus.
RCC PTA Application 2015
Page 1
Physical Therapist Assistant Application
Application Instructions
Before completing the application
 Review Physical Therapist Assistant Prerequisite requirements listed on the RCC web site and obtain
academic advising from RCC PTA Navigation Coach: contact Daniel Wu 541-245-7845.
 Complete observation requirements (25 minimum in two clinical settings) See Observation Verification Form
for additional information. (See pg. 3 for Work/Observation requirements).
 If you have never taken courses at RCC complete the online admission application:
http://www.roguecc.edu/Students/start.asp to obtain a student ID number.
 Complete LCC online admission application: http://www.lanecc.edu/counseling/steps-enroll and Financial
Aid application. You can contact Lane’s Financial Aide Department at 541-463-3100 or go to
http://www.lanecc.edu/sites/default/files/finaid/forms/1314guide.pdf for instructions on how to apply.
 Request official transcripts from prior colleges/universities for any non-RCC coursework that will be used to
meet prerequisite courses or placement requirements. Official transcripts must be received by RCC in the
original sealed envelope. You may use the Lane Transfer Tool to confirm LCC transfer equivalency.
Application Requirements: Email submissions to CMorris@roguecc.edu
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Apply to RCC with the appropriate student profile.
Complete Online PTA Application and submit via email a printed copy of the confirmation page.
Submit Official Transcripts for all non-RCC courses used for prerequisite requirements.
Complete and Submit via email Work/Observation Forms.
Complete and Submit via email Written Personal Statement of Interest.
Submit via email proof of Jackson/Josephine Co. residency, veteran/eligible spouse of veteran, or Trade Act
eligibility.
 Submit via email copies of Healthcare License or Certification(s).
Application Packet
The following must be received on or before June 19, 2015 at 5:00 pm by email:
1. Online Application Questionnaire
2. Official Transcripts (if using non-RCC courses to meet prerequisite requirements).
Items 3 -5 must be emailed to:
Christine Morris
CMorris@roguecc.edu
3. Observation Report Form and signed Verification Forms.
4. Written Personal Statement of Interest.
5. Additional Documentation: Proof of Jackson/Josephine County residency, Veteran’s (DD 214 or 215) or Trade
Act Affected (Forms 858 and 028) eligibility documentation.
6. Healthcare license and or Certification and a brief description of Healthcare work/volunteer experience.
RCC PTA Application 2015
Page 2
Physical Therapist Assistant Application
Work/Observation Requirement Information
RCC ID # _______________Last Name ______________________________ First ___________________
Print this document, record the necessary information, and submit along with your signed verification forms (page
6) in your completed Application Packet:
Agency Name
Therapist Name & Phone number
Setting
# of hours
Enter in the right hand column the total number of Work/Observation Hours
(Minimum 25 hours)
The minimum requirement for work/observation is 25 hours. Additionally, hours must be obtained from at least two different
clinical settings. Settings may be described as the following; 1. Outpatient, 2. Skilled Nursing Facility and 3. Acute Care (Hospital).
Acknowledgement Statement – RCC program coordinator may contact agencies listed above to verify hours and experience. I
understand that any inaccuracies in reporting work/observation hours could result in invalidating my application.
RCC PTA Application 2015
Page 3
Physical Therapist Assistant Application
Points Breakdown
Prerequisite coursework
Note: points will be awarded based upon completion of all prerequisite requirements. The following courses or their
RCC or LCC equivalents must be completed with a grade of “C” or better.
Math Requirement (Completion of Math 065 Course or Placement Test at Math 095 or higher is the
minimum requirement)
Math65
Placement testing at Math95 or higher, a higher level math class must be completed to obtain degree
Psychology Requirement
PSY201 or 202 General Psychology
Medical Terminology Requirement
MO100 Medical Terminology
Anatomy and Physiology Requirement (BI121 minimum requirement)
BI121 Elementary Anatomy & Physiology I
BI231 Anatomy and Physiology I
Writing Requirement (WR 121 minimum requirement)
W 121 English Composition I or higher
Prior Bachelor’s Degree (Submitted with transcript)
Physics Requirement (One course from the three options listed below)
GS104, PHY201 or PHY202
Additional points will be offered in the following categories:
Military Veteran or eligible spouse/ Or Trade Act Affected Employee
(Submission of DD 214 or 215 required)
(Submission of Forms 858 and 028 required for Trade Act)
4 points possible for above two categories
Healthcare work experience
(Paragraph describing experience and hours worked plus copy of license or certification if
applicable)-0-5 points
Personal Statement of Interest
(Maximum 2 page response) – 0 – 5 points
Interview-(Applies to 12 maximum finalists invited to interview)
Group Interview rubric-0-28 points
Interview Questions-0-45 points
Residents of Jackson/Josephine County will be given preference, verification documents required. See page 7
RCC PTA Application 2015
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Physical Therapist Assistant Application
Any ties between qualified applicants with the same point totals will be awarded first to Veteran’s or eligible spouses
and Trade Act eligible applicants; additional ties will be decided based upon the applicants’(a) number of points for
Personal Interest Statement, then (b) most recent term’s GPA as a full-time student.
Write a Personal Statement of Interest and include it in your application submission, more
information included in online application.
The personal statement allows you to tell the selection committee about yourself and your personal/professional
goals.
The American Physical Therapy Association embraces as its core values accountability, altruism, compassion and
caring, excellence, integrity, professional duty and social responsibility. Consider your experiences with physical
therapy – choose one experience and explain what you observed and how you believe these core values were
demonstrated. Include in your response how this experience may have shaped your short and long-term professional
goals.
Your response must be limited to 2 typed double pages (front/back) and must be double-spaced, 12 point font.
Include your RCC ID #, Last Name, First Name as a header on all pages of your personal statement.
The personal statement is used in screening candidates. This is a competitive program, and not all qualified
applicants may be accepted. The quality of your statement will be assessed from 0 – 5 points. Assessment categories
include; Idea and content, Organization and Subjective. Include this document in your completed Application Packet
via email. Plagiarism is considered a serious offense at RCC. If it is determined that your essay has been plagiarized or
purchased, you will be eliminated from consideration for the program.
In compliance with state and federal laws, Rogue Community College does not discriminate on the basis of race,
religion, color, national origin, age, sex, Veteran’s status, sexual orientation, marital status or disability in
employment, or in any of its educational programs or in the provision of benefits and services to students.
This project was funded $3,000,000 (100% of its total cost) from a grant awarded under the Trade Adjustment
Assistance Community College and Career Training Grants, as implemented by the U.S. Department of Labor’s
Employment and Training Administration.
Rogue Community College is an equal opportunity employer/program. Auxiliary aids and services, alternate form and
language services are available to individuals with disabilities and limited English proficiency free of cost upon
request.
RCC PTA Application 2015
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Physical Therapist Assistant Application
Observation/Work Experience Verification Form
Note to Applicant: Observation/Work Experience must be verified using this form. Be sure to complete the boxed
areas prior to submitting this form for verification. If this form is not signed it will not be considered.
Dear Human Resources,
I am in the process of making application to the Physical Therapy Assistant Program offered by Rogue Community
College in partnership with Lane Community College. The application process requests verification of direct
observation of Physical Therapy. Experience may take place in one or more locations. Please fill in the information in
the area below. The following information may be helpful in locating my records.
_______________________________________
Applicant’s name while at your facility
_________________________
dates at facility
OBSERVATION EXPERIENCE:
For Observation Experience, this form must be completed by the PT or PTA overseeing the Observation/Work Experience. Please
verify the setting, dates and hours the applicant observed direct Physical Therapy services (assessments or treatments) under
your supervision within the last 2 years (since April 2012). Be sure to completely fill out all applicable fields. Incomplete forms
cannot be considered in the application process. Eligible Settings: Acute (Hospital), Skilled Nursing, and Outpatient
This section to be completed by the facility employee verifying applicant’s Experience
□ Acute
Setting:
Dates of service:
Supervised by:
Name of Facility:
Facility Address:
□ Skilled Nursing
□ Outpatient
________________________________ Hours of service: __________________
_________________________________________________________________
Name
Title
Phone
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Authorizing Signature: ___________________________________
Date: _____________________
I authorize the college to contact the individuals listed on this form to verify the information provided.
Student Signature: __________________________________
Date: ___________________________
Please duplicate this form as needed.
RCC PTA Application 2015
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Physical Therapist Assistant Application
Jackson/Josephine County Residency Documentation
Verification for preference in the application process: A resident is defined as someone who established residency 90 days before
the first day applications are accepted for that program. Permanent residence is defined as the home a person intends to return to
after any absence, and in which one’s dependents reside for an unlimited period of time. You must complete the residency
information below and provide at least one document from Category 1 AND one document from Category 2 to prove your
permanent residency status.
CATEGORY 1 (One of A, B, or C)
A. Rent receipts with your resident address and dates of occupancy for the period of time in question. (Rental
agreements are not acceptable)
B. Power company receipt with your resident address and dates of occupancy.
C. Documents proving your own Oregon property and that this property is your primary residence.
CATEGORY 2 (One of below)
 Oregon driver’s license.
 Oregon vehicle registration with your resident address.
 Oregon state income tax return (for previous year) with resident address.
 Verification of local bank account showing resident address.
 Oregon voter registration.
 Oregon Hunting/Fishing license.
ALL documents must have your name and permanent address for the period of time in question. The address on these
documents must agree with the permanent address on your application form or the previous addresses you have listed
below.
COMPLETE THE INFORMATION BELOW
Name_________________________________________________Phone_________________________
ID # or SS# __________________________________________________________________________
Program for which you are requesting to establish your residency _______________________________
Please list all addresses you have lived at for the time period involved.
____________________________________________________________________________________
Street
City
State
Zip
____________________________________________________________________________________
Street
City
State
Zip
____________________________________________________________________________________
Street
City
State
Zip
List the two documents you are submitting to verify your permanent address.
Category 1 ________________________________ Category 2 _________________________________
The above information is a true and accurate statement of my residency.
Student signature
RCC PTA Application 2015
Date
Page 7