Thank you for your interest in the educational programs offered through Shifrin Healthcare, Inc. If you are offered acceptance to one of our courses of study in the health professions, you will be on your way to a brilliant new career with an education of the highest quality.

The best way to increase your chance of acceptance into any of our Physical Therapy programs, is to apply immediately. Shifrin Healthcare, Inc., can then open a file in your name. After you apply and your application has been received, you should call Shifrin Healthcare, Inc., and ask a representative for an application review.

Only one Shifrin Healthcare, Inc., application is required for any of our programs. You must submit additional transcripts and application fees for each program you apply to.

It is the applicants responsibility to submit all required documents by the deadline. All documents must be mailed together in one packet, and should be sent "Certified, Return Receipt Requested" to Shifrin Healthcare, Inc., 111 Columbia Turnpike, Florham Park, New Jersey 07932-2103.

Applications are being considered as they are received.

Checklist of required items:

• Completed application form

• Official Transcrips from every College or University attended. It is your responsibility to be sure that your pre-professional education meets the standards outlined in the accompanying literature.

• Two letters of recommendation on official letterhead, which may be from a medical doctor, a licensed Physical Therapist or other healthcare professional, a past employer, or a professor.

• An Autobiographical essay which discusses your interest in the field of Physical Therapy (one typed page).

• 50 hours minimum of either volunteer, work, or observation in a Physical Therapy settings.

• When your application is complete, press the send button below, print out a copy and mail it to us with the above information.

A letter of invitation for interviews will be sent to selected individuals. If your application is accepted, you will be expected to travel to our offices at your own expense for a personal interview with the University representatives.

1. Name    Date 

2. Permanent address

   Street   City  State   Zip 
	
	If you have an e-mail address, please type it here. 
	
3. Current address

   Street   City  State   Zip 

4. Birth date  Social Security # 

5. Telephone # Permanent ()

               Current   ()

6.  U.S. citizen  Yes      No    Permanent U.S. resident  Yes      No

    Country of Citizenship 

EDUCATION

7. High School attended 

8.List all schools (Colleges or Universities) attended in order:

     Most recent first:

   College or University 

      City  State  Zip 

      Major  Grade Point Average 

      Diploma or certificate received 



   College or University 

      City  State  Zip 

      Major  Grade Point Average 

      Diploma or certificate received 



   College or University 

      City  State  Zip 

      Major  Grade Point Average 

      Diploma or certificate received 



9. Please list any current enrollment:

   Are you currently enrolled in any academic institution?  Yes      No

   List the courses in which you are currently enrolled


       College                Course Name            Semester Hours      Date of Completion

     
     
     
     
     



10. List all the courses that you plan to take to complete you prerequisites:


       College                Course Name            Semester Hours      Date of Completion

     
     
     
     
     


11. Personal interests and activities:

    High School 

    College     

    Community   
    
                

EMPLOYMENT/WORK EXPERIENCE

12. List your most recent job experience, followed by previous employers.

         COMPANY                  CITY               POSITION/TITLE           DATES

a.    
b.    
c.    
d.    
e.    

   

VOLUNTEER/OBSERVATION/WORK EXPERIENCE IN PHYSICAL THERAPY

13. List any exposure that you have had to physical therapy or other
    health professions:

    Have you had experience as:
   
    PT assistant  Yes      No           PT aide  Yes      No

    PT volunteer  Yes      No           PT observer   Yes      No


14. Have you ever worked full time in a Physical Therapy department?

     Yes      No


15. Have you ever been convicted of a felony?  Yes      No


I hereby certify that I have made no willful misrepresentations nor
have I withheld information pertinent to this application.  I affirm
that the information I have given is accurate and true in all respects
and I agree to abide by the rules of the University should I gain
admission.


Signature of Applicant ______________________________ Date ________________

Shifrin Healthcare, Inc. admits students of any race, color religion, sex, age, and national or ethnic origin and to all the rights, privileges, programs and activities generally accorded or made available to students at the University. It does not discriminate on the basis of race, color, religion, sex, age, or national or ethnic origin administration of its educational policies, loan programs, or any other administered programs.

STUDENT PREREQUISITE SELF EVALUATION

SCIENCE PREREQUISITE COURSES

Course          Course #           School        Term Taken/Yr Credits Grade
                                                 
Biology I                

Physics I                

Physics II               

Chemistry I              

Chemistry II             

Anatomy & 
Physiology I             

Anatomy & 
Physiology II            

NON-SCIENCE PREREQUISITE COURSES

Course          Course #           School        Term Taken/Yr Credits Grade
                                                 
English                  

English                  

Math                     

Humanities               

Humanities               

Psychology