12901 Bruce B Downs Blvd, MDC77

Tampa, FL 33612

Student Admission Offer Response Form

              CHECK ALL THAT APPLY

q    Yes, I ACCEPT the offer of admissions as a member of the USF School of Physical Therapy & Rehabilitation Sciences DPT Class of 2018.

q    No, I DECLINE the offer of admissions as a member of the USF School of Physical Therapy & Rehabilitation Sciences DPT Class of 2018.

q    I am accepting an offer of admission for Physical Therapy study at another institution. Institution Name_______________________________________________________

q    Other________________________________________________________________

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ALL PREREQUISITE AND COURSE REQUIREMENTS AND THE   BACCALAUREATE DEGREE MUST BE COMPLETED BY JUNE 30, 2015.

_______ I DO NOT REQUIRE AN ACCOMMODATION OF THE TECHNICAL

               STANDARDS.

_______ I DO REQUIRE AN ACCOMMODATION OF THE TECHNICAL

               STANDARDS. THE ACCOMMODATION I REQUEST IS:

____________________________________________________________________________

_____________________________              __________________________________

Applicant Signature                                         Print Name and Date

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Social Security Number

_____________________________              Is this a new number? Yes or No

Daytime Phone

_____________________________              Is this a new address? Yes or No

Address

_____________________________                                                                    Revised 1/13/15