Prospective Student Information Request Form

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I am interested in a...

I am a prospective...

Are you a current high school student?

High School

Ceeb (hidden)

Expected Graduation Date:

Most Recent College/University Attended

College Ceeb (hidden)

Are you a licensed/certified Physical Therapist Assistant or enrolled in a Physical Therapist Assistant program? *

Please select the program below that most interests you:

Do you plan to take undergraduate level courses or graduate level courses?

What year are you planning to start school?

What semester are you interested in?

Student Contact Information

Student Legal First Name *

Preferred Name/Nickname

Student Legal Last Name *

Birthdate *

Email Address *

Mobile Phone Number *

May we text you?

Yes

No

Current Mailing Address *

Country

Street

City

Region

Postal Code

Please select your primary country of citizenship: *

Are you a U.S. Permanent Resident?

Yes

No

Please select your U.S. citizenship status:

Please select your current Visa status OR the Visa you intend to pursue:

Please select the program below that most interests you:

Anticipated Year to Start *

Starting Semester

Please choose a preferred campus/location: *

Questions/Comments: