Application for Selective Admission to Professional Phase
Athletic Training Education Program
Directions to Student(s):
Complete this application by typing your responses in the appropriate text box.
Some yes/no questions will need to be answered only after you have printed
your application. Students are to submit the following documents by April 1st
in order for his/her application to be considered complete:
Application Check-list
1. Completed Application Form including signed Technical Standards Statement.
2. Letter to Admissions Committee to demonstrate your interest and understanding for
admission into the athletic training education program at Nicholls.
a. Optional: Students may submit character recommendation letter(s) with
their application. (2 maximum)
3. Any documentation of previous athletic training experiences outside of ATTR 102
course requirements (If applicable)
Completed applications should be submitted to:
Mrs. Laurie Melancon, Administrative Assistant
Department of Allied Health Sciences
Office: Room 120 Ayo Hall
Phone: 985-493-2624
Hours: 7:30 am – noon / 1:00 – 4:00 pm
Athletic Training Admissions Committee
ATTN: Cary Berthelot, MA, ATC, LAT
ATTR Program Coordinator
Mailing Address
Office
PO Box 2090
Betsy C. Ayo Hall Room 115-A
Thibodaux, LA 70310
Phone: (985) 493-2615
Fax: (985) 493-2614
Cover Page
E-mail: cary.berthelot@nicholls.edu
Application for Selective Admission to Professional Phase
Athletic Training Education Program
Application Deadline April 2nd
Nicholls State University
College of Nursing & Allied Health
Department of Allied Health Sciences
PERSONAL DATA
I am applying for the Fall
Name:
2015
Term.
N#:
Last
First
MI
Permanent Address:
Local Address:
Street
Phone #:
City
Cell #:
State
Zip
E-mail:
PRE-REQUISITES
Applicants must have a minimum of 22 credit hours completed, as required in the current curriculum, prior to
acceptance in the program which must include a grade of "C" or better in the following courses:
Use IP (in progress) if you are currently enrolled. (*students may be permitted to complete coursework in the
summer term; however, all pre-requisites must be completed prior to the start of the fall semester).
COURSE #
COURSE NAME
CREDITS
ATTR 101
Careers in Sports Medicine
1
ATTR 102
Clinical Intro to Athletic Training
2
BIOL 114
Anatomy & Physiology I
3
BIOL 115
Anatomy & Physiology Lab I
1
BIOL 116 *
Anatomy & Physiology II
3
WHEN & WHERE TAKEN
GRADE
Transfer Students: Copies of transcripts are required from all colleges as proof of attendance and grades.
EDUCATION
Please check any of the following that apply:

I am currently enrolled at Nicholls State University.

I am not currently enrolled at Nicholls State University, but I have been admitted as a transfer student for
the
Term
Year.

I am a licensed or certified health care professional:
Title:
License / Certification #:
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Application for Selective Admission to Professional Phase
Athletic Training Education Program
SCHOOLS ATTENDED
HIGH SCHOOL ATTENDED
ACT/SAT
SCORE
GPA
COLLEGES ATTENDED
MAJOR
GPA
ACTIVITIES/ HONORS
YEARS
ATTENDED
ACTIVITIES/ HONORS
CRIMINAL BACKGROUND CHECK NOTIFICATION
Athletic training is one of many health care professional disciplines who are required to complete criminal
background checks. Students admitted to the Athletic Training Program will be required to submit to criminal
background checks as a part of placement to some clinical site(s). Be advised, misdemeanor or felony records
may prevent placement at clinical sites and may prevent eligibility for licensure as an athletic trainer.
Please answer the following:
1.
I have been found in violation of student conduct
(including academic conduct) at any college or university.
____ Yes
____ No
2. I understand that criminal backgrounds checks and/or fingerprinting
will be required for placement at some clinical sites.
____ Yes
____ No
3. I agree to notify the Athletic Training Program immediately
regarding any changes to my criminal or academic background.
____ Yes
____ No
If you have questions or concerns about criminal background checks, please contact the ATTR Program
Director so that your needs and career aspirations can be fully evaluated. Failure to answer these questions
will delay the processing of your application.
ATHLETIC TRAINING EXPERIENCE & OBSERVATION HOURS
Do you have any previous experience as an athletic training student? If so:
High School, College, or Other:
Additional athletic training
experience (workshops,
clinics, summer teams, etc.):
Are you presently a member of the National Athletic Trainers’ Association or of any related associations?
If yes, please list:
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Application for Selective Admission to Professional Phase
Athletic Training Education Program
ADDITIONAL INFORMATION
Please provide any additional information that you would like to be considered as part of this application:
REVIEW OF TECHNICAL STANDARDS
The Athletic Training (ATTR) Program at Nicholls State University is a rigorous and intense academic program that
places specific requirements and demands on the students enrolled in the clinical phase of the program. An
objective of this program is to prepare graduates to enter a variety of employment settings and to render care to a
wide spectrum of individuals engaged in physical activity. The technical standards set forth by the ATTR establish
the essential qualities, considered necessary for students admitted to this program, to achieve the knowledge,
skills, and competencies of an entry-level athletic trainer, as well as meet the expectations of the program’s
accrediting agency, the Commission on Accreditation of Athletic Training Education (CAATE). A physical
examination by a MD/DO/NP/PA must verify that the student is able to meet the physical and mental requirements with or without reasonable accommodation - of an athletic trainer. All students admitted to the ATTR must meet
the requirements for the following abilities and skills. In the event a student is unable to meet the technical
standards of the ATTR, with or without reasonable accommodation, the student will be subject to failing a clinical
course and consequently not permitted to progress in the program.
Nicholls State University is committed to the principle that no qualified individual with a disability shall, on the basis
of disability, be excluded from participation in or denied the benefits of the services, programs, or activities of the
University, or be subjected to discrimination by the University as required by the Americans with Disabilities Act of
1990. However, Nicholls State University cannot and does not waive the published degree requirements for ATTR
students. To the extent practical, Nicholls State University will make a reasonable accommodation to assist
otherwise qualified individuals with disabilities to fulfill their degree requirements, consistent with applicable
federal and state law, policies of the Louisiana Board of Regents and Nicholls State University. Each applicant is
required to complete a physical examination which includes verification by the appropriate health care provider
signifying the student is, or is not, able to fulfill these technical standards, with or without reasonable
accommodation. Student(s) cannot be admitted into the program without both the student and physician
verifications.
Candidates for selection to the Athletic Training Program must demonstrate:
1. The mental capacity to assimilate, analyze, synthesize, integrate concepts and problem solve to formulate
assessment and therapeutic judgments and to be able to distinguish deviations from the norm;
2. Sufficient postural and neuromuscular control, sensory function, and coordination to perform appropriate
physical examinations using accepted techniques; and accurately, safely and efficiently use equipment and
materials during the assessment and treatment of patients;
3. The ability to communicate effectively and sensitively with patients and colleagues, including individuals from
different cultural and social backgrounds; this includes, but is not limited to, the ability to establish rapport with
patients and communicate judgments and treatment information effectively. Students must be able to
understand and speak the English language at a level consistent with competent professional practice;
4. The ability to record the physical examination results and a treatment plan clearly and accurately;
5. The capacity to maintain composure and continue to function well during periods of high stress;
6. The perseverance, diligence and commitment to complete the athletic training education program as outlined
and sequenced;
7. Flexibility and the ability to adjust to changing situations and uncertainty in clinical situations;
8. Affective skills and appropriate demeanor and rapport that relate to professional education and quality patient
care.
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Application for Selective Admission to Professional Phase
Athletic Training Education Program
Candidates for selection to the ATTR will be required to verify they understand and meet these technical standards
or that they believe that, with certain accommodations, they can meet the standards. The Office of Disability
Services (158-A Shaver Gym) will evaluate any student who states he/she could meet the program's technical
standards with accommodation and confirm that the stated condition qualifies as a disability under applicable laws.
If a student states he/she can meet the technical standards with accommodation, then the University will determine
whether it agrees that the student can meet the technical standards with reasonable accommodation. This would
include a review to determine whether the accommodations requested are reasonable, taking into account
whether accommodation would jeopardize clinician/patient safety, or the educational process of the student or the
institution, including all coursework, clinical experiences and internships/externships deemed essential to
graduation.
The following is a list of physical, cognitive, psychomotor, and affective variables that may impact essential
work related functions of the entry-level athletic trainer:
A. Visual Acuity
 Ability to see all colors of the spectrum
 Ability to distinguish calibrated markers
 Ability to identify digital displays and controls in differing lighted environments
 Ability to determine the depth of instrument placement
 Ability to read small print on medical instrumentation or containers
B. Hearing Acuity
 Ability to hear alarms, beeper, and pages
 Ability to hear and respond to verbal communication in the work setting
 Ability to distinguish different alarm sounds/tones on medical devices
C.
Physical Acuity
 Ability to perform all ranges of body motions including walking, bending, stretching, reaching, and twisting of
the upper and lower back.
 Ability to lift 35 pounds (weight of small child or small equipment) alone
 Ability to stand and/or sit for long periods of time
 Ability to perform CPR; use of hands for manually compressing resuscitation equipment, and the use of hands
and body for performing chest compressions
 Ability to write legible for required documentation
 Ability to move swiftly when the situation demands
D. Communication
 Ability to communicate with physicians, coaches, co-workers, other health care workers, the athlete and the
athlete’s family
E.
Mental Stress
 Ability to function appropriately under stress without hesitations using all knowledge and skills require to
perform the task at hand
 Ability to work long hours (8 to 12 hours), adapting to changes in the clinical schedule and/or emergency
situations
 Ability to function as a team member and to follow the appropriate administrative protocol and/or chain of
command
 Ability to review and use student-athlete data in a confidential and professional manner
 Ability to make quick, life saving decisions
F.
Clinical Behavior Requirements
 Must be patient, kind, and tactful in dealing with athletes and their families
 Must understand that all information obtained in the clinical facilities is strictly confidential and it is not to be
discussed outside the training room
 Must attend clinical experiences as required.
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Application for Selective Admission to Professional Phase
Athletic Training Education Program
Name:
N#:
Last

First
MI
Statement for students NOT requesting accommodations
I certify that I have read and understand the technical standards listed above, and I believe, to the best of my
knowledge, that I can meet each of these standards without accommodation. I understand that if I am
admitted and unable to meet these standards, then I will not be permitted to progress in the program.
Applicant Signature: ______________________________________

Date: ____________________________
Alternative statement for student requesting accommodations
I certify that I have read and understand the technical standards listed above and I believe, to the best of my
knowledge, that I can meet each of these standards with certain accommodations. I must contact the Office
of Student Disability Services to determine what accommodations may be available. I understand that if I am
unable to meet these standards with or without accommodations, I may not be admitted into the program.
Applicant Signature: ______________________________________
Date: ____________________________
I certify that the information given in this application is complete and accurate, and I
understand that making false or fraudulent statements within this application may
result in disciplinary action, denial of admission and invalidation of credits or degrees
earned.
Applicant Signature: _______________________________
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Date: ________________