Master of Science in Physician Assistant Studies Supplemental Application Form • Application Deadline: March 1, 2014

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.

     
Section 1

PLEASE PROVIDE THE FOLLOWING INFORMATION

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Section 2

BACHELOR'S DEGREE INFORMATION

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Section 3

To be eligible for 2014 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(s)
     
     
     
     
     
     
     
     
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(address, e-mail, and phone number)

     

(address, e-mail, and phone number)

     

(address, e-mail, and phone number)

     

(address, e-mail, and phone number)

     
Section 4

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 completed 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.

     
     
     
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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:

     
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 College, 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.

     
Section 5
     
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 for the forwarding of official transcripts from colleges and/or universities I have attended and that such transcripts become the property of Alderson-Broaddus College 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 in 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 College’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 College, which may delay or prevent their completion of the Physician Assistant Studies Program; and (2) that they will hold the College harmless and not bring any type of legal action against the College 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 on the Program website at www.ab.edu/academics/master-science-physician-assistant-studies

     

By typing your name here, this serves as an electronic signature, confirming all information on this application is accurate to the best of your knowledge.

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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.

     

COURSE#, COURSE NAME, CREDIT HOURS, EXPECTED DATE OF COMPLETION, INSTITUTION

     

COURSE#, COURSE NAME, CREDIT HOURS, EXPECTED DATE OF COMPLETION, INSTITUTION

     

COURSE#, COURSE NAME, CREDIT HOURS, EXPECTED DATE OF COMPLETION, INSTITUTION

     

COURSE#, COURSE NAME, CREDIT HOURS, EXPECTED DATE OF COMPLETION, INSTITUTION

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If pre-requisites are not complete, please indicate your plan for meeting the requirements