Step Up Program Application

For consideration to participate in the program, the following must be submitted:

Completed Candidate, Demographic, and Education & Community Involvement Information (below)
Personal Statement (no more than 500 words): Highlight why you are interested in a career in Athletic Training, Occupational Therapy, Physical Therapy, or Speech Language Pathology. If you are not sure about a specific discipline, please comment on why you are interested in the degree programs offered through rehabilitation sciences.
Copy of an unofficial college transcript

CANDIDATE INFORMATION

First Name

Middle Name

Last Name

If you have a preferred name, please enter it here:

Other (Please specify if you use a combination of the above)

Birthdate

Sex

In which health discipline are you interested (check all that apply):

Athletic Training

Occupational Therapy

Physical Therapy

Speech Language Pathology

If selected to be a part of this program, please indicate if you will require housing:

Yes

No

CONTACT INFORMATION

Email Address (non-school email address preferred)

Mailing Address

Country

Street

City

Region

Postal Code

Mobile Phone Number

Home Phone Number

I permit Thomas Jefferson University to contact me via text and voice messaging. Standard messaging rates may apply.

Yes

No

Parent/Guardian or Emergency Contact Person

**An emergency contact person may be listed in place of a parent/guardian if the applicant is 21 years or older.

Name

Address

Home Phone Number

Mobile Phone Number

Email Address

DEMOGRAPHIC INFORMATION

Colleges and universities are asked by many groups, including the federal government, accrediting associations, college guides, and newspapers, to describe the ethnic/racial backgrounds of their students and employees. In order to respond to these requests, we ask you to answer the following two questions.

Are you Hispanic or Latino?

Yes

No

Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:

Is English your native language?

Yes

No

Are you the first generation in your family to attend/pursue a graduate degree (parents/grandparents have not pursued or completed graduate studies)?

Yes

No

Please share any additional information you would like us to know that you feel is important related to your personal circumstances and/or how you would benefit from this program.

CITIZENSHIP

Primary Citizenship

Are you a US Permanent Resident?

Yes

No

EDUCATION AND COMMUNITY INVOLVEMENT

What is your current undergraduate institution?

Current Class

Please list any academic honors you have earned

Please list any extracurricular activities (student clubs, athletics, student government, etc.) in which you have engaged during your undergraduate studies

Please list any experience (volunteer or shadowing) that you have had in a healthcare environment. Please describe.

OPTIONAL CLINICAL OBSERVATION

The program planning committee is considering adding clinical observations into the program; however, to be approved to shadow in the health system, all participants would need to obtain a physical, bloodwork to prove immunity to your childhood immunizations, a Pennsylvania Criminal Background Check, a Pennsylvania Child Abuse Clearance, and FBI Fingerprinting. This will also have to be at your expense. Knowing the requirements to observe, is this an optional activity that you would like to see added to the program?

Yes

No

Maybe

DISCLOSURES

Have you ever been disciplined by any high school, college, or university for unacceptable academic performance, inclusive of academic probation, suspension, and dismissal?

Yes

No

If yes, please explain.

Have you ever been disciplined by any high school, college, or university for conduct violations?

Yes

No

If yes, please explain.

Have you ever been convicted of a crime, including a felony or misdemeanor, or do you currently have any criminal charges pending against you in any court? Please note that conviction includes judgment, found guilty by a judge or jury, pleaded guilty or nolo contendere, received probation without verdict, disposition in lieu of trial, or ARD.

Yes

No

If yes, please explain.

CERTIFICATION

By choosing "I Agree", I certify that the information I have provided on this application is complete and accurate. I understand that all records submitted in support of an application become property of Thomas Jefferson University and cannot be released to the application, any institution, or third party. I understand that deliberate falsification, misrepresentation, or omission of information on this application or my credentials, may result in the denial or revocation of admission and, if enrolled, will result in disciplinary action including dismissal from Thomas Jefferson University.

I Agree

UPLOAD DOCUMENTS

Submit your unofficial transcripts and personal statement using the button below.

Unofficial Transcript

Personal Statement