Physical Therapy Observation Documentation

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Applicant Name*

First Name

Last Name

I have completed volunteer or paid work at the following facility.

Facility Name*

Facility Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Type of work*

Inpatient Outpatient Additional Setting Service/Community Project

Clock Hours*

Dates*

Contact Name*

First Name

Last Name

Contact Phone*

Contact Email Address*

Did you observe or volunteer at any other facilities?*

Yes No

I have completed volunteer or paid work at the following facility. (Facility #2)

Facility Name*

Facility Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Type of work*

Inpatient Outpatient Additional Setting Service/Community Project

Clock Hours*

Dates*

Contact Name*

First Name

Last Name

Contact Phone*

Contact Email Address*

Did you observe or volunteer at any other facilities?*

Yes No

I have completed volunteer or paid work at the following facility. (Facility #3)

Facility Name*

Facility Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Type of work*

Inpatient Outpatient Additional Setting Service/Community Project

Clock Hours*

Dates*

Contact Name*

First Name

Last Name

Contact Phone*

Contact Email Address*

Did you observe or volunteer at any other facilities?*

Yes No

I have completed volunteer or paid work at the following facility. (Facility #4)

Facility Name*

Facility Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Type of work*

Inpatient Outpatient Additional Setting Service/Community Project

Clock Hours*

Dates*

Contact Name*

First Name

Last Name

Contact Phone*

Contact Email Address*

Did you observe or volunteer at any other facilities?*

Yes No

I have completed volunteer or paid work at the following facility. (Facility #5)

Facility Name*

Facility Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Type of work*

Inpatient Outpatient Additional Setting Service/Community Project

Clock Hours*

Dates*

Contact Name*

First Name

Last Name

Contact Phone*

Contact Email Address*

Signature

I authorize the above named facility/facilities to release any information regarding my volunteer/work experience to the OKCU Doctor of Physical Therapy (DPT) Program. I understand that submitting any false information to the OKCU DPT Program will make my application for admission, as well as any future applications, subject to denial, or will result in expulsion from the College. I also understand that all documents submitted to the DPT Program at Oklahoma City University become the property of the OKCU DPT Program and will not be returned to me.

Date

Signature

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Type your name here as confirmation of your electronic signature.*

First Name

Last Name