2013
1002
00
Sports Physical Therapy Residency
FALL
Application
APPLICANT INFORMATION
Date of Application:
Last Name:
First:
Middle:
Prior Names Used (Maiden Name):
Credentials (PT, DPT, OCS, etc):
Date of Birth: (mm/dd/yyyy)
COHORT AND WEEKEND INTENSIVE SITE SELECTION
Cohorts (please check preferred start date):
Winter (January) 2014
Summer (July) 2014
Program(s) (please check one option):
EIM Sports Physical Therapy Residency
EIM Combined Postprofessional DPT / Sports PT Residency
Weekend Intensive (WI) Locations : All EIM Management Courses are offered in dual track system. You will be assigned to a
curricular track based on your primary Weekend Intensive location.
Track A Program Management Course Sequencing: 1) Lumbopelvic Disorders, 2) Lower Extremity Disorders, 3) Cervical and Thoracic
Disorders and 4) Upper Extremity Disorders
Track B Program Management Course Sequencing: 1) Cervical and Thoracic Disorders, 2) Upper Extremity Disorders, 3) Lumbopelvic
Disorders, 4) Lower Extremity Disorders.
Please select and prioritize your first three choices for weekend intensive locations by listing a 1, 2, or 3 beside three of the locations
below. Please note that your final assignment of weekend intensive location will be based upon your preferences indicated as well
as site and space availability. You will be notified of your weekend intensive location(s) in your acceptance letter and
automatically enrolled for each management course.
Track A:
Track B:
____ Arlington, Virginia (Mid Atlantic Consortium: consists of
Body Dynamics, Gold Medal PT, Loudon PT, Restore
Motion, Results Rehab & Fitness, and Total Motion PT)
____ Austin, Texas (Texas Physical Therapy Specialists)
____ Atlanta, Georgia (Benchmark Physical Therapy)
____ Chicago, Illinois (AthletiCo)
____ Baton Rouge, Louisiana (Baton Rouge Physical Therapy)*
____ Fresno, California (Terrio Therapy-Fitness)
____ Chicago, Illinois (ATI Physical Therapy)
____ Evansville, Indiana (ProRehab)*
____ Guilford, Connecticut (PTSMC) & Kingston, Rhode Island
(University of Rhode Island) These 2 locations are a
consortium that will alternate WI offerings in 2014
____ Tacoma, Washington (Apple Physical Therapy)
____ Green Bay, Wisconsin (Bellin Physical Therapy)
____ Norman, Oklahoma (Physical Therapy Central)*
____ Ortonville, Minnesota (Big Stone)
____ Roseville, California (Sutter Health)
*This location will only offer one course in 2014, not all Weekend Intensives will be held at this site.
***Sports Competency Course WI required for all Sports Residency students - The Weekend Intensive for the Sports Competencies
Course will be conducted in Denver, Colorado only. The other four Weekend Intensives will be conducted at your location of
choosing from above. Please note that final assignment will be based upon site and space availability.
How did you hear about EIM’s Sports Residency Program?
If you haven’t already done so, please establish a MyEIM account (free) at: http://my.evidenceinmotion.com/MyEIM.aspx
If you already have a MyEIM account, please make sure your information is current.
CONTACT INFORMATION (PLEASE DO NOT ENTER P.O BOX #. PHYSICAL ADDRESS NECESSARY FOR PROGRAM MATERIAL SHIPMENTS)
Student preferred Email Address:
Preferred Phone Number:
Secondary Email Address:
Secondary Phone Number:
Home Address:
City & State/Province/Territory:
(Please indicate if St, Ave, Rd, etc.)
Country:
Postal Code:
EMPLOYMENT INFORMATION (ALL FIELDS REQUIRED BY ALL APPLICANTS)
Are you employed by an EIM Network Partner (see list of WI sites listed above)?
Yes
No
Employer:
Work Email Address:
Phone Number:
Address:
City:
State:
Zip:
Which of the following best describes your current primary position?
Academic administrator or director of PT/PTA education
Researcher
program
Sole owner of PT practice or business
Academic Faculty Member
Staff PT
Consultant
Supervisor/Director of PT practice
Director of Residency/Fellowship program
Other _____________________________
Partner in PT practice or business
Please estimate the number of hours per week you currently spend in clinical practice providing physical therapy services for
patients. (Note: Include time spent in administrative aspects of providing patient care such as scheduling, coding, documentation,
etc. as time spent in clinical practice.)
0-10 hours/week
21-30 hours/week
40+ hours/week
11-20 hours/week
31-40 hours/week
How many years have you been active in clinical practice?
BILLING INFORMATION-PLEASE INDICATE WHO WILL HANDLE INVOICES/PAYMENT (PLEASE DO NOT ENTER P.O BOX #.)
*THIS SECTION MUST BE COMPLETED FOR APPLICATION TO BE PROCESSED
Self
Employer ____________________________________________________(person in charge of billing)
Email Address:
Phone Number
Address:
City:
(Please indicate if St, Ave, Rd, etc.)
State:
Zip:
ACADEMIC BACKGROUND
What degree were you awarded upon completion of your entry-level PT education?
Baccalaureate
Name of Institution:
Master’s (MPT, MS, etc.)
DPT
Year of Graduation:
What is your highest earned PT related degree?
Baccalaureate
Post-Baccalaureate Certificate
Entry Level Doctorate (i.e. DPT, TDPT)
Name of Institution:
Entry Level Master’s (i.e. MPT, MS)
Post Professional Clinical Doctorate (i.e. DHSc, DSc)
Other ______________________
Year of Graduation:
Please list physical therapy licensure information (*MUST PROVIDE COPY OF LICENSE WITH APPLICATION)
State:
License #:
Expiration:
CPR Certification (must provide proof of certification):
Date:
Expiration:
Please list any previous APTA credentialed residency/fellowship programs that you have completed:
Program:
Practice specialty:
Year Completed
Clinical Electro-physiology
Residency
Hand
Fellowship
Manual PT
Orthopaedic PT
Pediatrics
Women’s Health
Please list any ABPTS board certifications you hold:
Practice Specialty:
Certification #
Expiration
Clinical Electro-physiology
Geriatrics
Neurological
Orthopaedics
Pediatrics
Sports
Women’s Health
PROFESSIONAL MEMBERSHIPS
Do you have a current APTA Membership?
Yes Member number : ________________
No (Required for Resident and Fellow Applicants, please apply for membership)
What sections do you belong to?
Acute Care
Home Health
Aquatic PT
Neurology
Cardiovascular & Pulmonary
Orthopaedic
Clinical Electro-physiology
Pediatric
Education
Private Practice
Federal PT
Research
Geriatric
Sports PT
Hand Rehabilitation
Women’s Health
Health Policy and Administration
Are you a member of the American Academy of Orthopaedic and Manual Physical Therapists? (AAOMPT)
Yes Member number: _________________
No
APPLICANTS TRAINED OUTSIDE OF THE UNITED STATES
1. Are you currently licensed in the United States?
Yes (Please list State, License #, and expiration__________________________________________________________________________)
No (Please see # 2 below)
2. If your answer to question 1 is No, all applicants who have graduated from a university outside of the US and who are not currently
licensed in the US must provide an official physical therapy degree equivalency evaluation for admission. The prospective student
will pay for this evaluation. EIM requires an evaluation for the Transition DPT program from one of the FSBPT (Foreign Educated
Physical Therapist Committee) approved agencies that use the Coursework Tool (CWT) to evaluate equivalency. The approved
agencies include the following:
- Foreign Credentialing Commission on Physical Therapy (FCCPT): http://www.fccpt.org/
- International Consultants of Delaware (ICD): http://www.icdeval.com/
- International Education Research Foundation, Inc (IERF): http://www.ierf.org/
- World Education Services (WES): http://www.wes.org/
3. Is the English language your (please check all that apply):
Native/first language
Language used in your physical therapy / physiotherapy education
Primary language for your daily professional / clinical practice
None of the above.
If English is not your First/Native language, what is your primary language?_______________________________________________
4. If your answer to the question above was "None of the above", then you will need to meet the following language proficiency
requirement:
- TOEFL (Test of English as a Foreign Language) – Internet-based: Minimum score of 82 on the TOEFL.
- TOEFL – Computer-based: Minimum score of 213.
- Paper-based: Minimum scores of 550.
- Note: Our TOEFL code is 7315, please place this on your application so that we receive your scores.
The TOEFL is administered by TOEFL/TSE Services, PO Box 6151, Princeton, NJ, 08541-6151, USA (609) 771-7100
Information is available on the Internet at www.toefl.org.
PROFESSIONAL LIABILITY INSURANCE (REQUIRED FOR RESIDENCY APPLICANTS - PLEASE PROVIDE COPY WITH
APPLICATION)
Please provide your malpractice insurance information:
Carrier:
Policy Number:
Expires:
MENTORSHIP (REQUIRED FOR RESIDENCY APPLICANTS)
Clinical Mentor: Please designate a mentor to supervise the clinical practicum component of the Orthopaedic Residency, Sports
Residency, or Fellowship program.
I do not have this information at this time. I understand it is a requirement for the program and I must submit my mentor
information to EIM no later than 8 weeks after the program start date.
Last Name:
First:
Clinic Name:
Clinic website:
Phone:
Email:
Sports Venue Mentor: Please designate a mentor to supervise the sports venue mentorship component of the Sports Residency
program only.
I do not have this information at this time. I understand it is a requirement for the program and I must submit my mentor
information to EIM no later than 8 weeks after the program start date.
Last Name:
First:
Phone:
Email:
Evidence in Motion Residency and Fellowship programs are credentialed through the American Board
of Physical Therapy Residency & Fellowship Education (ABPTRFE). Students in these programs are
prohibited from participating in ANY clinical or supervised mentoring in a physician-owned or referral
for profit facility. Please contact EIM directly for further clarification on this policy.
By checking this box, I understand this policy and verify that I do not work in and will not conduct
clinical or supervised mentoring in a physician-owned or referral for profit facility.
* Acknowledgement is required for admission to the program.
FOCUS ON THERAPEUTIC OUTCOMES (FOTO)- (OUTCOMES TRACKING FOR RESIDENCY)
Do you have a current FOTO account that you use?
Yes (please provide your Clinic Name and Username:____________________________________________________________________
No, please sign me up for an account
OFFICIAL TRANSCRIPTS FROM CAPTE ACCREDITED PROFESSIONAL PROGRAM (REQUIRED FOR COMBINED
POSTPROFESSIONAL DPT / SPORTS RESIDENCY APPLICANTS ONLY)
All applicants must have successfully completed a CAPTE accredited professional physical therapy curriculum, or have had a state
physical therapy board approve the applicant’s first-professional physical therapy program as “equivalent” to a US CAPTE accredited
professional physical therapy program.
Applicants from CAPTE accredited professional programs should request that official transcripts be sent directly to EIM from the
institution where the physical therapy degree was awarded. Official transcripts can be mailed or sent electronically. EIM accepts
electronic transcripts from the following services: Scrip-Safe, Docufide, Avow Systems.
I have requested that my official transcripts be sent to EIM and understand that my application will not be determined complete
until EIM receives the document(s).
POSTPROFESSIONAL DPT (TRANSITION) IN MUSCULOSKELETAL MANAGEMENT ACKNOWLEDGEMENT
All EIM Postprofessional DPT In Musculoskeletal Management Applicants must review EIM’s Postprofessional DPT Frequently Asked
Questions document, which describes EIM’s position on this degree. Please click link (or copy and paste into browser) to review.
http://www.evidenceinmotion.com/wp-content/uploads/2012/07/EIM-tDPTFAQ_Postprofessional-v.3.pdf
By checking this box, I verify that I have reviewed and understand the linked document (above). I
recognize that although EIM is licensed as a proprietary educational organization and follows the APTA
Preferred Curricular Guide for its Postprofessional DPT, it is not a regionally accredited university.
* Acknowledgement is required for admission to the program.
STATEMENT OF INTEREST: REQUIRED FOR ALL APPLICANTS
REQUIRED ITEMS TO EMAIL / MAIL TO EVIDENCE IN MOTION: Please check to verify all submitted
Please fill out the application (ALL Applicants) electronically (i.e. MS Word) and save by using your
last name, a space, and then first name. If you really want to impress, then save or print these
electronically as a pdf file. Please e-mail the completed application forms to
admissions@eimpt.com. Applications can also be faxed to 1-866-936-2759.
An alternate option is to mail a hard-copy to:
Evidence in Motion
Attn: Application Submissions
17325 Bell North Drive, Suite 2B
Schertz, TX 78154-3368
Electronic or hard copy of Statement of Interest (ALL Applicants)
Electronic or hard copy of your current and valid Physical Therapy License(s) (All Applicants)
Electronic or hard copy of your CPR certificate (Residents and Fellows Only)
Electronic or hard copy of Professional Liability Insurance (Residents and Fellows Only)
Electronic or hard copy of your ATC, EMT or EMR certificate or scheduled class (Sports Residency
Applicants Only)
Electronic or hard copy of your Physical Therapy degree equivalency evaluation (Applicants trained
outside of the US Only)
Please check here to verify your TOEFL submission with code 7315 (Applicants trained outside of the
US Only)
$100 Application fee, non-refundable (*REQUIRED FOR ALL APPLICANTS TO PROCESS APPLICATION)
*** Please call the billing office at 1-888-709-7096 to make all payments
Discount Promotion Code:______________________________________________________________________
STATEMENT OF EXPECTATIONS (*MUST BE SIGNED FOR APPLICATION TO BE PROCESSED)
The EIM Residency programs include a combination of distance-based and live on-site intensive course
components. This means that applicants should be technically proficient in basic internet use as well as
able to travel to the on-site intensive course events. By checking the box below, you acknowledge that
you have read this statement, understand its implications, and agree to the aforementioned conditions.
I agree to the above statement:
Yes
No
Signature:
(*SIGNATURE IS REQUIRED FOR APPLICATION TO BE PROCESSED)
Date:
Verification Email sent upon successful completion of application and payment
Once we receive your application and application fee ($100.00, non-refundable) you will be contacted
regarding your acceptance status. Acceptance letters will be sent 4 weeks prior to the cohort start date.
Please contact us at info@eimpt.com if you have questions on the residency or fellowship programs. Contact
us at TDPT@eimpt.com if you have questions specifically about our DPT program.
Thank you for applying. We look forward to the possibility of having you join our programs.
Sincerely,
The Evidence in Motion Team
Payment Information
A) Program Fees (per participant – please note that prices are subject to change).
Please refer to the EIM Website http://evidenceinmotion.com/pricepage.aspx for most current pricing.
All prices listed here are in US dollars, and all payments should be in US dollars.
Sports Physical Therapy Residency (SPTR)
SPTR + Postprofessional DPT Combined
1.
2.
3.
$ 13,625 (plus $100 application fee)
$ 16,075 (plus $100 application fee)
Postprofessional DPT tuition may be less if a revised Plan of Study, based on prior EIM coursework taken and PTET
scores, is approved.
Fees listed do not include travel related expenses for weekend intensives.
Actual tuition fees may be less if participant is affiliated with a current EIM Network Partner or Program Affiliate.
B) Sports Residency Program Course Waiver/Credit
Online and hybrid courses (multi-week online didactics with an onsite weekend intensive) taken
through EIM within the prior 36 months can be credited toward this program if requested.
Students attending an EIM Weekend Intensive course as a CE participant within two (2) years of
applying to an EIM program may receive a $300 tuition credit per course. While tuition credit is
granted, the student will be required to repeat the WI at no cost. This allows the student to take
the WI as part of the Management course and complete requisite skills check that are not
required of a CE participant.