UNIVERSITY OF DELAWARE
Advancing Diversity in Physical Therapy (ADaPT)
Application for ADaPT
University of Delaware Rising Juniors & Seniors
DEADLINE: March 22, 2013
First Name:
Last Name:
UDID #:
Mailing Address:
Telephone:
E-mail:
I. Please indicate your ethnicity and racial identity by selecting one or more of the
categories below, as provided:
Ethnicity (Please check one)
Hispanic or Latino
Not Hispanic or Latino
Race (Please check all that apply)
Black or African American
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
White
II.
Education:
College/University
Major
Years attended
Degree(s) or date
expected
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III.
Physical Therapy Related Work/Volunteer Experience:
Please indicate any physical therapy work or volunteer experience you have earned.
Facility
Dates
Job Description
Supervisor/Title
Approximate #
of total hours in
this job
IV.
Letter of Reference – See Reference Form located at
http://www.udel.edu/PT/ADaPT/Downloads/ADaPT_recomform.pdf.
One letter of reference from an upper-level instructor of a course taken at the University of
Delaware is required. Please ask your instructor to submit their letter electronically to Jeanne
Warrington at jeannekw@udel.edu or mail it to her in a sealed envelope to 301 McKinly Lab.
Name
Title
Department
Phone #
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V. List any of the following DPT pre-requisite courses that you have taken.
Prerequisite
Course Name Credits
Institution
Grade Semester/Yr.
Biology I with lab
(4)
Biology II with
lab (4)
*Anatomy with
lab (4)
*Physiology with
lab (4)
Physics I with lab
(4)
Physics II with lab
(4)
Chemistry I with
lab (4)
Chemistry II
with lab (4)
Statistics (3)
Psychology (3)
*May substitute 2-course sequence of anatomy & physiology
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VI.
Please write a short essay (Limit: 500 words) on the following statement.
Of all of the healthcare professions, why are you interested in choosing physical
therapy as a career path? In your response, please elaborate on why physical therapy
is an appealing career choice beyond the opportunity to help people.
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Please answer the following question:
Have you ever been charged or convicted of a crime? If yes, please explain.
I hereby certify that I have made no willful misrepresentations nor have I withheld information
pertinent to this application. I understand that the information given by me in this application will
be investigated (transcripts, references, etc.).
_____________
Signature of Applicant
Date
Please submit your completed application to:
Jeanne Warrington at jeannekw@udel.edu or
Department of Physical Therapy
University of Delaware
301 McKinly Lab
Newark, DE 19716
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