OTA Program Application | Canyons Forms

Refer to the OTA Program Application Checklist to make sure you have completed the application process thoroughly and accurately. Applicants who submit incomplete applications or who are missing any required documents will automatically be ineligible.

Your application must be completed within 2 hours. You will not be able to save and return to make any changes or submit at a later time. Only one application submission per application cycle is allowed.

Student First Name

Student Last Name

Date of Birth

Street Address

City

State

Zip

Phone Number

Alternative Phone Number

My Canyons Email

Verify My Canyons Email

COC STUDENT ID #

Have you attended a College of the Canyons OTA Information session?

Yes

If yes, what date did you attend?

Have you ever attended another OTA Program or any program that included placement in a clinical facility?

Yes

If yes, specify which OTA Program & Institution

Are you a U.S. citizen?

Yes

Are you lawfully eligible to work in the U.S.?

Yes

Demographic Information Statement

The following information is collected solely for accreditation, reporting, and statistical purposes, including compliance with accreditation requirements. All responses are confidential and will be used only in aggregate form.

Providing this information is voluntary. The decision to provide or not provide the information requested below will not impact an applicant’s eligibility, admission status, or standing in the OTA Program.

Demographic Information

Gender

Male

Female

Other

Decline to State

Highest Level of Education Completed to Date

High School Diploma / GED

Some College (No Degree)

Associate Degree

Bachelor’s Degree

Master’s Degree or Higher

If applicable, graduation or completion date (Month/Year)

Employment Status

Are you currently employed?

Yes

Employer Name

Position/Role

Average Hours per Week

Length of Employment (months/years)

Educational Background

List All Colleges Attended (include College of the Canyons, universities/military, USA/foreign; failure to list all colleges attended will result in ineligibility.)

College Information

Name of College	Degree Earned	Operations
Name of College	Degree Earned

To list all college attended, use + and – to add or delete colleges. One college per line.

College/University Degree Posted on Transcript?

Yes

Previously applied to any Health Professions program at College of the Canyons?

Yes

If yes, please explain which program and when did you apply?

Previously completed the ATI TEAS – Version 7 (effective June 2022)?

Yes

If yes, please provide date and location

Prerequisite Coursework Status

Do you currently have any required prerequisites in progress?

Yes

Number of prerequisite courses currently in progress

Other

List each prerequisite course in progress

Prerequisites

Course Name	Institution	Term	Expected Completion Date	Operations
Course Name	Institution	Term	Expected Completion Date

To list all prerequisites, use + and – to add or delete prerequisites. One prerequisite per line.

Will all prerequisite courses be completed by the end of Spring 2026?

Yes

If no, please provide expected completion date/s

Multicriteria Screening

Experience

Rehab Aid

Therapy Technician

PTA

SLPA

Relevant Work or Volunteer Experience

Experience Information

List work experience, however, if you are submitting a letter of employment (below), do not list the same work experience in this section.

Direct patient care and/or employed in acute care, skilled nursing facilities, outpatient clinics, school districts, and home health/caregiver setting for 6 months within the last 5 years (must attach verification of employment letter from your employer as proof of at least 6 months employment within the last 5 years on official letterhead, signed by employer. Letter must include your name, job title, brief job description, and dates of employment. (.pdf files only)

Life Experiences

Disabilities

(The same meaning as used in Section 2626 of the Unemployment Insurance Code)

Yes

Low Family Income

(Measured in terms of a student's eligibility for, or receipt of, financial aid under a program that may include, but is not necessarily limited to, a fee waiver from the Board of Governors, The Cal Grant Program, the federal Pell Grant program or CalWORKS)

Yes

First generation of family to attend college

Yes

Need to Work

(The student is working at least part time while completing academic work that is a prerequisite for admission to the nursing program)

Yes

Disadvantaged social or emotional environment

Yes

Difficult personal and family situations or circumstances

Yes

If yes, please briefly describe

Refugee or veteran status

Yes

If yes, please provide your military ID

Language Proficiency

Proficiency or advanced level coursework in languages other than English (list below)

Language Proficiency Information

Applicant Certification

Education Level

My signature is mandated and indicates that I have completed all sections truthfully. I understand that should I be admitted to the COC OTA program, any falsification, misrepresentation, or omissions of facts are sufficient reason for dismissal upon discovery at any time during the OTA program. I authorize the release of College of the Canyons transcripts and all college transcripts to the COC Kinesiology, Health & Wellness, Fitness, and Athletics Department when I apply and each semester that I am a part of the program. I will provide further documentation if requested.

Student Signature

Persons with Disabilities

It is your responsibility to notify the Disabled Students Programs and Services office at the College with verified documentation from a health or learning specialist in order to receive reasonable accommodation.

Non-Discrimination Policy

The Kinesiology, Health & Wellness, Fitness, and Athletics Department does not discriminate on the basis of ethnic group identity, religion, sex, age, color, national origin, marital status, sexual orientation, veteran’s status, mental disability or physical disability including persons with AIDS/ARC/HIV in any of its polices, procedures, or practices. This non-discrimination statement covers admission and access to, and treatment and employment in the programs, services and activities.

File Uploads

Please attach the applicable documents needed to complete your OTA Application as .pdf FILES ONLY.

If you checked the box indicating no college degree posted, you must attach copy of high school transcript, OR copy of diploma, OR copy of GED certificate. If from foreign country, you must provide translation from an official agency.
If you checked the box indicating your employment in direct patient care and/or in an acute care setting, skilled nursing facilities, outpatient clinics, school districts, and home health/caregiver for 6 months within the last 5 years, you must attach verification of employment letter from your employer, as proof of at least 6 months employment within the last 5 years on official letterhead, signed by employer. Letter must include your name, job title, brief job description, and dates of employment.

File Uploads

Maximum 10 files.
15 MB limit.
Allowed types: pdf.