NAIOMT Sports Residency Program Application Survey

1.Residency Applicant Information(Required.)

Name (please include credentials, ie. PT, DPT, ATC, etc.)

Company

Address

Address 2

City/Town

State/Prov

ZIP/Postal Code

Country

Email Address (personal not work email)

Phone Number

2.Enter Birth Date(Required.)

Date

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3.CLICK HERE to read the Residency Program admission requirements.(Required.)

I acknowledge I have read the Residency Program admission requirements.

5.What PT school did you graduate from?(Required.)

6.Please provide a one paragraph biography below (name, credentials, PT school, date of graduation, current pending employment name and location and other professional information.(Required.)

7.Graduation date(Required.)

Date / Time

Date

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8.Highest degree awarded(Required.)

MSPT

BSPT

DPT

9.Are you an APTA member in good standing? Note: You must be a current APTA member in good standing prior to, and for the duration of the residency training.(Required.)

Yes

No

10.What is your APTA membership number?(Required.)

11.Are you a member of AAOMPT?(Required.)

Yes

No

If you answered "yes" to this question, please provide your membership number.

12.Do you currently have, or have ever had, an ABPTS Certification?(Required.)

Yes

No

If you answered "yes" to this question, what ABPTS do you, or did you, hold?

14.Have you taken any NAIOMT courses?(Required.)

Yes

No

If you answered "yes" to this question, what NAIOMT courses have you previously taken?

15.Licensure State(Required.)

16.License Expiration Date(Required.)

Date

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MoMonday

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17.Please provide the name, email address and phone number of 3 references. [first name, last name/phone number/email address](Required.)

Reference #1

Reference #2

Reference #3

18.Do you have a conviction record or pending charges?(Required.)

Yes

No

If you answered "yes", please provide details below.

19.Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction?(Required.)

Yes

No

20.Have you ever had any license, certificate, registration, or other privilege to practice a health care profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority?(Required.)

Yes

No

21.Have you ever surrendered a credential in connection with, or to avoid, action by a state, federal, or foreign authority?(Required.)

Yes

No

22.Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)? (Required.)

Yes

No

23.Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of a health care profession? (Required.)

Yes

No

24.If you answered “yes” to any of the questions (17-22), the comments box below provides an option to explain the circumstances. (Required.)

25.Current Employer Name(Required.)

Advanced Kinetics Physical Therapy and Sports Performance

Marathon Physical Therapy and Sports Performance

PRN Physical Therapy

Phoenix Physical Therapy

Other (please specify)

26.Employer Information(Required.)

Name of Supervisor

Company

Address

Address 2

City/Town

State/Prov

ZIP/Postal Code

Country

Employer/Supervisor's Email Address

Employer/Supervisor's Phone Number

27.Have you negotiated participation in the NAIOMT Sports Residency Program with your employer? *NOTE – Participants in this residency must be employed by one of our clinical practice partners at an ABPTRFE-approved site.(Required.)

Yes

No

28.Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? “Currently” means within the past two years. “Chemical substances” include alcohol, drugs, and/or medications whether taken legally or illegally(Required.)

Yes

No

29.Are you currently engaged in the illegal use controlled substance(s)?“Currently” means within the past two years. Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine) not obtained legally or according to the directions of a licensed health care practitioner. (Required.)

Yes

No

30.Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety?(Required.)

Yes

No

31.Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism, or frotteurism?(Required.)

Yes

No

32.Upload your CV(Required.)

No file chosen

33.Upload a one paragraph biography. Include your school and professional history and what you like to do in your time outside of work.

No file chosen

34.Upload a head and shoulder photo in JPG format.(Required.)

No file chosen

35.I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me for the residency program. (Required.)

Yes

36.Please enter date(Required.)

Date / Time

Date

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**ABPTRFE has granted NAIOMT's sports residency program candidacy status. Candidacy status signifies satisfactory progress toward accreditation. Achieving candidacy status is not an indication that ABPTRFE will grant initial accreditation. Participants who graduate from a program in candidacy status are not deemed to have completed an accredited program.