PTA Program Admissions Reference Form
Name of Student: __________________________________________________
This student is interested in seeking admission to the Kirkwood Community College
Physical Therapist Assistant Program. The following information is requested to assist
with the admission process.
Reference Name:___________________________________________________
Address___________________________________________________________
__________________________________________________________________
Phone Number: _____________________________________________________
Email: _____________________________________________________________
Please provide answers to the following questions:
1. Length of time that you have known this student?
2. In what capacity have you known this student?
Please rank the applicant on a scale of 1-5 in the following professionalism behaviors,
using the following definitions:
5= excellent
4= good
3= fair
2= poor
1= this student does not display this behavior
5
4
1. Cooperation with others/
Teamwork
2. Attendance and Promptness
3. Problem Solving
4. Dependability/ Responsibility
5. Participation/ Initiative
6. Verbal and Non Verbal
Communication Skills
7. Organization
8. Ability to Use Constructive
Feedback
9. Appropriate Attire
10. Self Control of Emotions/ Ability to
Handle Stress
3
2
1
Comments:
Please list any specific examples that you have of outstanding behavior in the areas
that you rank at a 5.
Additionally, any comments that you have to add about this students potential for
success at a Physical Therapist Assistant would be appreciated.
Please put this signed reference form in a sealed envelope and sign your name across
the closing of the envelope. You may then give it to the student to return, or send to the
address below:
Physical Therapist Assistant Program
Kirkwood Community College Linn Regional Center
1770 Boyson Road
Hiawatha, Iowa 52233
Thank you very much for your assistance with the PTA Admissions Process!