Evidence In Motion Education & Training Programs
Manual Therapy Certification Application
CONTACT INFORMATION (PLEASE DO NOT ENTER P.O BOX #. PHYSICAL ADDRESS NECESSRY FOR PROGRAM MATERIAL SHIPMENTS) Student preferred Email Address: Preferred Phone Number:
Secondary Email Address: Secondary Phone Number
Home Address: (Please indicate if St, Ave, Rd, etc.)
City: State: Zip Code:
APPLICANT INFORMATION Date of Application:
Last Name: First: Middle:
Prior Names Used (Maiden Name):
Professional Credentials: Date of Birth:
Cohorts (circle preferred start date): Winter (January) or Summer (July)
Weekend Intensive Locations (host site): Please note that your final assignment of weekend intensive location will be based upon preferences indicated as well as site and space availability. Please select your first three choices in order by listing a 1, 2, or 3 beside three of the locations below. You will be notified of your weekend intensive location in your acceptance letter. Upon payment for each management course, you will be automatically enrolled the associated weekend intensive location assigned in your acceptance letter.
US Locations:
____ Arlington, Virginia (Body Dynamics) ____ Evansville, Indiana (ProRehab)*
____ Atlanta, Georgia (Benchmark Physical Therapy) ____ Green Bay, Wisconsin (Bellin Physical Therapy) ____ Austin, Texas (Texas Physical Therapy Specialists) ____ Indianapolis, Indiana (St. Vincent)
____ Bakersfield, California (Terrio Therapy-Fitness) ____ Newark, Delaware (ATI/PRO Physical Therapy) ____ Baton Rouge, Louisiana (Baton Rouge Physical Therapy)* ____ Norman, Oklahoma (Physical Therapy Central) ____ Boise, Idaho (St. Luke’s/Elks Rehab) ____ Minneapolis, Minnesota (OSI Physical Therapy) ____ Chicago, Illinois (AthletiCo)
____ Chicago, Illinois (ATI Physical Therapy)
____ Roseville, California (Sutter Health)
____ Tacoma, Washington (Apple Physical Therapy)
*Not all Weekend Intensives will be held at this site.
If you haven’t already done so, please establish a MyEIM account (free) at:
. If you already have a MyEIM account, please make sure your
information is current.
EMPLOYMENT INFORMATION
Are you employed by one of the EIM Network Partners listed on page 1 (Weekend Intensive Locations)? Yes No Name of Company:
Work Email Address: Phone Number:
Address:
City: State: Zip Code:
Which of the following best describes your current primary position? Academic administrator or director of PT education
program
Academic Faculty Member Consultant
Partner in PT practice or business
Researcher
Sole owner of PT practice or business Staff PT
Supervisor/Director of PT practice Other _____________________________
Please estimate the number of hours per week you currently spend in clinical practice providing physical therapy services for patients. (Note: Include time spent in administrative aspects of providing patient care such as scheduling, coding, documentation, etc. as time spent in clinical practice.)
0-10 hours/week
11-20 hours/week 21-30 hours/week 31-40 hours/week 40+ hours/week How many years have you been active in clinical practice? ______
ACADEMIC BACKGROUND
What degrees were you awarded upon completion of your professional (i.e. entry to practice) physiotherapy education? Baccalaureate Master’s (MPT, MS, etc.) DPT
Name and Location of Institution: Year of Graduation: What is your highest earned PT related degree?
Baccalaureate Post-Baccalaureate Certificate Entry Level Master’s (i.e. MPT, MS)
Entry Level Doctorate (i.e. DPT,) Post Professional Clinical Doctorate (i.e. DHSc, DSc) Other ______________________ Name & Location of Institution:
Year of Graduation:
Please list any previous Manual Therapy Certification courses (from EIM or other provider) that you have completed:
Program Name(s): Courses completed: Year Completed
Please list physical therapy licensure information (must provide current copy of PT license):
State: License # : Expiration:
CPR Certification (must provide proof of certification):
Please list any ABPTS board certifications you hold:
Practice Specialty: Certification # Expiration
Clinical Electro-physiology Geriatrics Neurological Orthopaedics Pediatrics Sports Women’s Health PROFESSIONAL MEMBERSHIPS
Do you have a current APTA Membership?
Yes Member number : ________________ No What sections do you belong to?
Acute Care Aquatic PT
Cardiovascular & Pulmonary Clinical Electro-physiology Education
Federal PT Geriatric
Hand Rehabilitation
Health Policy and Administration
Home Health Neurology Orthopaedic Pediatric Private Practice Research Sports PT Women’s Health
APPLICANTS TRAINED OUTSIDE OF THE UNITED STATES 1.Is the English language your:
Native/first language
Language used in your physical therapy / physiotherapy education Primary language for your daily professional / clinical practice None of the above.
If English is not your First/Native language, what is your primary language?_______________________________________________ 2. If English is not the applicants native/first language, he/she must meet the following language proficiency requirement:
TOEFL (Test of English as a Foreign Language) – Internet-based: Minimum score of 82 on the TOEFL. TOEFL – Computer-based: Minimum score of 213.
Paper-based: Minimum scores of 550.
Note: Our TOEFL code is 7315, please place this on your application so that we receive your scores. The TOEFL is administered by TOEFL/TSE Services, PO Box 6151, Princeton, NJ, 08541-6151, USA (609) 771-7100 Information is available on the Internet at www.toefl.org.
BILLING INFORMATION
Please choose your preferred method of billing for your Program;
Student-Pay as you go through Program
(students will NOT be enrolled in coursework until payment is
received for each course. Note: It is the student’s responsibility to call EIM office to make payment.)
Self-student billed/invoiced for Program
(students will be auto enrolled in coursework)
-An initial tuition payment (coordinated with Finance Office) is due within the first 30 days of the start of
the program, with remaining balance due in four equal installments based on timeframe of
course work. Please coordinate with Finance Office at
[email protected]
.
Employer Billed-invoiced for coursework
(students will be auto enrolled in coursework)
-Payment schedule is coordinated with Finance Office at
[email protected]
.
Billing information for responsible party Please note all payments must be made in US dollars
Name:________________________________________________________________________________________________
Email address(all invoices will be sent electronically):
___________________________________________________
REQUIRED ITEMS TO EMAIL / MAIL TO EVIDENCE IN MOTION: Please check to verify all submitted
Please fill out the application (ALL Applicants) electronically
(i.e. MS Word) and save by using your
last name, a space, and then first name
. If you really want to impress, then save or print these
electronically as a pdf file. Please e-mail the completed application forms together to
[email protected]
.
An alternate option is to mail a hard-copy to:
Evidence in Motion
17325 Bell North Drive, Suite 2B
Schertz, TX 78154-3368
Attn: Application Submissions
Electronic or hard copy of your current and valid Physical Therapy License(s)
Electronic or hard copy of your CPR certificate
Please check here to verify your TOEFL submission with code 7315
(Applicants trained outside of the US Only)
$100 US Application fee (ALL Applicants)
***
Please call the San Antonio office at 1-888-709-7096 to make all payments
How did you hear about EIM’s Manual Therapy Certification?
______________________________________________________________________________________
______________________________________________________________________________________
STATEMENT OF EXPECTATIONSThe EIM Manual Therapy Certification includes a combination of distance-based and live on-site intensive course components. This means that applicants should be technically proficient in basic internet use as well as able to travel to the on-site intensive course events. By checking the box below, you acknowledge that you have read this statement, understand its implications, and agree to the aforementioned conditions.
I agree to the above statement: Yes No
Signature: Date:
Verification Email sent upon successful completion of application and payment
The registrar will contact you to confirm receipt of your application and application fee ($100.00,
non-refundable). Acceptance letters will be sent via email after review and verification of all application
requirements. Contact us at
[email protected]
if you have questions specifically about our Manual Therapy
Certification program.
Thank you for applying. We look forward to the possibility of having you join our programs.
Sincerely,
The Evidence in Motion Team
Payment Information
A)
Program Fees
(per participant – please note that prices are subject to change). Please refer to the EIM
Website
!for most current pricing. All prices listed here are in US dollars,
and all payments should be in US dollars.
Manual Therapy Certification (MTC) $ 7,150 US (plus $100 application fee & $550 materials fee)
*Fees listed do not include travel related expenses for weekend intensives.
B)
Manual Therapy Certification Course Waiver/Credit
Applicants who have completed other manipulative therapy certification coursework and/or
the Evidence In Motion Trigger Point Dry Needling/Instrumented Soft Tissue Mobilization Course
may be eligible for course waiver. Please contact EIM if you feel you qualify for such a
waiver/constructive credit. Please note regardless of waiver, every student must take at least
three of the four Management Courses (EIM 102, EIM 103, EIM 104, EIM 105) as a component of
their MTC program.
Online and hybrid courses (multi-week online didactics with an onsite weekend intensive)
taken through EIM within the prior 36 months can be credited toward this MTC program if
requested. Note that this does not apply to standard weekend continuing education
coursework.
C)
Manual Therapy Certification Payment Terms
1.
The application fee is due upon submission of the application.
2.
The materials fee ($550) is due upon receipt of acceptance letter (prior to first
management course).
3.
Participants may choose to register and pay for each course on a course-by-course basis.
It is the responsibility of the student to contact the EIM office (1-888-709-7096) prior to each
course to make payment (Please note: student will NOT be enrolled in coursework until
payment is made).
4.
Participants may choose to enroll in a tuition-based payment program. An initial tuition
payment of $1,150 is due within the first 30 days of the start of the program with the
remainder of the tuition balance due in four equal installments based on duration of your
Program. Please contact EIM’s billing department (502-413-6184 or
[email protected]
) if
you would like to take advantage of this option.
5.
Payment may be made via cash, check, credit card, or money order. For your
convenience EIM can set up automatic payments via credit card. Please contact EIM’s
billing department (502-413-6184 or
[email protected]
) if you would like to take advantage
of this option.
6.
EIM is happy to accommodate direct billing to Sponsoring Organizations (e.g. employers)
where applicable. Please contact EIM’s billing department at
[email protected]
to
facilitate this request.
7.
Please note that EIM reserves the right to provide individual student grades and
performance detail to each student’s corresponding Sponsoring Organization if requested.
8.
A late fee of $100 will be assessed by EIM if payment is made after the due date.
D)
Manual Therapy Certification Refund Policy
1.
EIM recognizes that conditions can occur that may necessitate a withdrawal from the
Program.
2.
The application fee and materials are non-refundable.
3.
The programming fee is partially refundable prior to 15
thday from acceptance letter
date or fully refundable within 48 hours of acceptance letter date.
4.
A refund of a portion of the individual course tuition payments made for individuals who
must withdraw from the Program will be provided as follows:
Week of Program
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Length of Course
