Physical Therapist Assistant (PTA) Information Request

Request Information

Please fill out the form to request information for the PTA program.

Please correct the following errors:

Personal Info

Name:

First Name

Last Name

High School:

Please enter the name of the High School you attended (or are attending).

Graduation Year:

Please enter your High School graduation year.

Contact Information

Email:

Phone:

Address:

Street/Mailing Address

City

State

Zip/Postal Code