Occupational Therapy Assistant Online Application

First Name:*

Middle Name:

Last Name:*

Mailing Address:*

City:*

State:*

Zip Code:*

Tech T #:

Date of Birth:*

Phone Number:*

Email:*

Please indicate if you are currently a student of:*

Arkansas Tech University

Arkansas Tech University-Ozark Campus

Another University

Have you previously attended another Occupational Therapy Assisting program?*

No

Yes

If you answered yes to the previous question, where?

Acknowledgment of Essential Functions*

Without reasonable accommodations

With reasonable accommodations

By selecting one of the choices above, I acknowledge that I have read and understand the Essential Functions for the Occupational Therapy Assistant Student. I believe to the best of my knowledge that I have the ability to learn and perform the essential functions:

I, the undersigned applicant to the Occupational Therapy Assistant program at Arkansas Tech University- Ozark Campus, understand that participation in a clinical experience is part of the Occupational Therapy Assistant program and that participation in a clinical experience includes working as a student at an affiliating agency. I understand that I will be responsible for all travel, meals and lodging associated with clinical education. I further understand that affiliating agencies have the right to establish requirements for participation in clinical experience. I understand that I am responsible for providing copies of the documentation requested by the affiliated agency. I understand and agree that if I am rejected for participation in a clinical experience by an affiliating agency or if I refuse to submit to checks or tests that are required by an affiliating agency in order to participate in a clinical experience, I may be unable to complete my program of study and graduate from the Occupational Therapy Assistant program. I hereby release Arkansas Tech University Ozark Campus, its employees, and all affiliating agencies from any liability with regard to my participation in a clinical experience and decisions made concerning my participation in a clinical experience. *

Yes, I understand

No

I, the undersigned applicant to the Occupational Therapy Assistant program at Arkansas Tech University Ozark Campus, understand that additional forms that can be found on the ATU-Ozark Occupational Therapy Assistant webpage must be submitted to the Allied Health Administrative Assistant BEFORE the program application deadline in order for my application to be considered complete. I also understand that, if I complete the online application but do not submit these additional forms, my application will not be considered for admission to the program, as my application would not be fully submitted.

Yes, I understand and will submit the additional documents

No