THE UNIVERSITY OF TEXAS MEDICAL BRANCH AT GALVESTON SCHOOL OF ALLIED HEALTH SCIENCES DEPARTMENT OF PHYSICAL THERAPY UT Telecampus IMPRINTS Program IMPRINTS Application
Name:
Mailing Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email Address:
Ethnicity:	White, Non-Hispanic Black, Non-Hispanic Hispanic Asian / Pacific Islander American Indian / Alaskan Native Other (Completion of this question if voluntary)
	Do you want to claim an ADA recognized disability? Yes No (Completion of this question if voluntary)
	Why are you interested in the IMPRINTS program?
	How does this program relate to your long-term goals as a physical therapist or other health care or early intervention provider?
	Are you currently working in an early intervention, NICU, or other pediatric setting? Yes No
	If yes, please describe:
	Are you a member of the APTA or other national professional association? Yes No
	If yes, please describe:
	Please list your prior degrees: Degree: University: Year: Degree: University: Year: Degree: University: Year:
	Are you a licensed physical therapist or other licensed health care professional? Yes No
	If yes, indicate Profession: License #: State where licensed:
	APPLICATION NOT COMPLETED UNTIL ALL FORMS ARE RECEIVED.