DOCUMENTATION OF PHYSICAL THERAPY EXPERIENCE
STUDENT NAME:__________________________________________________________________
THE ABOVE STUDENT HAS VOLUNTEERED OR WORKED FOR ME AT THE FOLLOWING:
PHYSICAL THERAPY FACILITY: ____________________________________________________
ADDRESS: ________________________________________________________________________
CITY, STATE, ZIP CODE: ___________________________________________________________
PHONE NUMBER: _________________________________________________________________
POSITION HELD:
PAID _______
VOLUNTEER ________
HOURS WORKED _________
STUDENT RECEIVED EXPOSURE TO:
_____GYM
_____HYDRO
_____PEDIATRICS
_____MODALITIES
_____GERIATRICS
_____ORTHOPEDICS
_____NEURO
_____BEDSIDES
_____ATHLETICS
_____AMPUTEES
_____OCC-INJ
_____MED-SURG
STUDENT PARTICIPATED IN:
_____TRANSFERS
_____EXERCISES
_____INSERVICES
_____HOUSEKEEPING
Date:________________
_____MODALITIES
_____CLERICAL WORK
Signature:__________________________________________
Registered or Licensed Physical Therapist
License #: ____________________________
This form may be duplicated and sent to the appropriate number of physical therapists.
You must have at least 50 hours of experience by the December 15 application deadline. It is suggested that these
hours come from a variety of PT settings. Observation or work experience in Physical Therapy (50 hours
minimum) under the supervision of a licensed Physical Therapist must be completed and must be verified and
submitted electronically to PTCAS and must include the PT’s license number.