APPLICATION INSTRUCTIONS:

This Supplemental Application Form is required as one of the components to complete the application process for potential admission into the Master of Science in Physician Assistant Studies Program at Alderson Broaddus University.

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Master of Science in PA Studies Supplemental Application

::::::: PERSONAL INFORMATION

Name
CASPA ID
Phone Number

::::::: BACHELOR'S DEGREE INFORMATION

Degree
Major
Date of graduation
If pre-requisites are not complete, please indicate your plan for meting the requirements. Please enter the course #, course name, credit hours, expected date of completion, and the institution.
Course 1
Course 2
Course 3
Course 4

::::::: ELIGIBILITY INFORMATION

To be eligible for admissions, applicants are required to complete and document 40 hours of Physician Assistant shadowing by date of the Program interview, if offered.
Physician Assistant Shadow Experience
Name of PA shadowed - 1
# of hours
Date
PA Address
PA Phone Number
Name of PA shadowed - 2
# of hours
Date
PA Address
PA Phone Number
Name of PA shadowed - 3
# of hours
Date
PA Address
PA Phone Number
Drug Test
If accepted, all applicants must submit the results of a background check and drug test, at the expense of the applicant. (The vendor will be chosen by the Physician Assistant Studies Program.) Directions and deadlines will be supplied and must be followed. The Physician Assistant Studies Program reserves the right to deny admission to any applicant whose drug test is positive for illicit substances. Any applicant who declines to take the drug test will be denied admission to the program.
Health Insurance, Physical Exam and Immunization Requirements
Applicants admitted into the Program must supply official documentation to verify proof of health insurance coverage after an offer of acceptance has been made. A physical examination and required immunizations must be complied by deadline supplied.
Background Information
The Physician Assistant Studies Program will deny admission to any applicant whose criminal background interferes with the ability of the Program to place the student in a supervised clinical practice experience.
Have you ever been charge with a felony or misdemeanor?
Have you ever been convicted of a felony or misdemeanor?
Do you currently have any charges pending?
If the answer to any of the above questions is “Yes” please indicate the charge involved, outcome, and the year(s), state, county, and country in which the legal proceedings took place:
Description
0 /
BACKGROUND INFORMATION NOTE: Should the answer to any of the above questions become "Yes" between the time of submission of this application and an applicant's enrollment at Alderson Broaddus University, the applicant must immediately inform the Director of the Physician Assistant Studies Program. Failure to comply will result in the applicant's dismissal from the Program.

::::::: APPLICANT UNDERSTANDING AND SIGNATURE

I certify that the information given on this application is complete and correct to the best of my knowledge. I understand that I am responsible for arranging got the forwarding of official transcripts from colleges and/or universities I have attended and that such transcripts become the property of Alderson Broaddus University and will not be returned. I understand that any falsification on my records will be cause for the Physician Assistant program to void my admission or registration or to take other appropriate action. I understand that the Physician Assistant Studies Program will require me to submit to criminal background checks and drug testing if I am accepted to become a student of the Program. I further understand that the results of those checks and tests may affect my eligibility to continue in the Program. Specifically, I understand that all students who accept the offer for admission into the University's Physician Assistant Studies Program, by their enrollment into the Program, agree (1) that they have been advised that they may be excluded by health care providers from participation in certain clerkships, through no fault or control of the University, which may delay or prevent their completion of the Physician Assistant Studies Program; and (2) that they will hold the University harmless and not bring any type of legal action against the University for any damages of any nature whatsoever that they may sustain as a result of their inability to be placed in required clerkships due to the results of their criminal background checks or their drug tests. I understand that I must be able to meet the Technical Standards of the Program which may be viewed here.
NOTICE
By printing your name here, this serves as an electronic signature, confirming all information on this application is accurate to the best of your knowledge.
Digital Signature (Name)
Date
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