PTA Interest Survey: Memorial Medical Center, Springfield

This information is optional. However, it will provide contact information that will allow SIUC to forward information about this program if it becomes available.
First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Home/Cell Phone:

Work Phone:

Email Address:


Yes, I am interested in learning more about SIUC's Associate in Applied Science degree in Physical Therapist Assistant that will be delivered at Memorial Medical Center in Springfield, Illinois

I would most likely enroll in this program in the following semester (check one)
Fall 2010
Fall 2011
Fall 2012

I have already completed the following courses
(these are NOT required to be completed prior to acceptance into the program)

Introduction to Psychology
Medical Terminology
Introduction to Physiology/Anatomy
General Biology
English Composition
Interpersonal Communications
First Aid and CPR
Child Psychology

Please click the Submit button when you are finished.

THANK YOU FOR TAKING YOUR TIME TO COMPLETE THIS SURVEY