Document Request Form ACORP Alliance canadienne des forganismes de réglementation de la physiothérapie CAPR Ly ol Pystrny Regulators Instructions to Applicants: 1. Complete Section 1 of the Document Request Form. 2. Send the form to your school/institution to complete. Your school/institution must send the completed form directly to The Canadian Alliance of Physiotherapy Regulators 1243 Islington Avenue, Suite 501 Toronto, ON CANADA M8X 1Y9 For information about the application process and other required documents please CUwauCe Required Documents List. If you have any questions please contact us at [email protected]. Important Note: Your school/institution must be listed as the sender on all envelopes and packaging sent to our office. If it is not sent directly to our office from your school/institution, we will not accept the documents and you will be required to have them resubmitted. | alliancept.or: x | ptorgprea s Request Form CAPR | ACORP Canadian Aliance | Alliance canadienne des ww af Physiotherapy | organismes dereglementation Regulators dela physitherapie Section 1: Applicant to complete before submitting to educational institution First Name: SHREYAKUMARI _ Middle Name: HITESHBHAI PAREKH Last Name’ Former Last Name (if applicable): ___ Date of Birth: Month/Day/Year 10/23/1996 CAPR Client ID# (if known}: ©1909 I hereby authorize the release of my educational records to the Canadian Alliance of Physiotherapy Regulators (CAPR) 09/11/2024 Applicant signature Date Instructions to Educational Institution: 1. The Registrar, Controller of Examinations, or other authorized official such as a Principal, Dean or Head of Department must complete Section 2 of this form, 2. Place the completed form in an envelope, ensuring the institution stamps and seals are on the envelope and the institution is listed as the sender of the package, including courier packages. 3. Send the sealed envelope to CAPR. Do not send this document to the student. We will not accept the documents from the student. 4, Please do not use digital or electronic signatures, or digital or electronic seals/stamps on this document. We require you to complete this form using your original signature and original stamp and/or seal where specified on the form. | x TR | alliancept.org |ACORP Alliance canadienne des organismes de réglementation de la physiothérapie PloCa ial s Request Form CAPR ae es Section 2: Educational institution to complete before submitting to the Canadian Alliance of Physiotherapy Regulators (CAPR) Name of person completing this form (print): Job title of person completing this form: Date Month/Day/Year: Signature School Seal/Stamp Name of school/educational institution: Institution Address: Telephone: Email: a. alliancept.orgDocument ale Carer rocone. Relea ee NA cn” | Stpipsncane ‘Student Information: ‘Student name: Student date of birth: Month/Day/Year. Name of degree, diploma, or certificate awarded: Dates of attendance: From: Month/Day/Year__ To: Month/Day/Year Date degree, diploma, or certificate was issued to the student: Did the student transfer to this program from another institution? Yes no[_] If yes, what institution did they transfer from? Program Information: ‘What is the name of the authority legally entitled to accredit your institution? Does this program prepare students for entry-level physiotherapy practice in your country? Yes No. Can the student work as a physiotherapist immediately following graduation? Yes No If no, what other requirements must the student meet to be able to be able to work as a physiotherapist? For example, are there requirements such as a national exam, internship period, or registration with a regulatory body or Ministry of Health? Please provide as much information as possible. OR alliancept.orgDocument CAPR | ACORP Canadian Alliance | Alliance canadienne des Request Form feat” | selapmoneene Supervised Clinical Practice: Definition: Supervised clinical practice consists of supervised and evaluated experience asa physiotherapist-in- training within an entry-to-practice program, where the student gains practical experience and engages in a range of professional opportunities in various settings, for the purpose of learning and applying physiotherapy knowledge, skills, behaviours and clinical reasoning. Supervised inical practice does not include academic classroom hours or practice on other students or staff. Please complete the following sections (including the chart). Include the locations, dates, areas of practice, and hours the student completed during each clinical placement as part of the program. All fields must be completed. Total hours of supervised clinical practice completed during the program: Locamions DATES | HOURS IN HouRSIN | HOURSIN HOURS IN | TOTAL Include the full name Start | Musculoskeletal | Neurological | Cardiorespiratory | Other | Hours ‘of hospital/clinic toEnd | Conditions Conditions | Conditions Conditions VENUS HOSPITAL, SURAT Toro12018 rontraor8 ° ‘SPB PHYSIOTHERAPY COLLEGE vava016 SURAT svadtzore ° 'SHREE PRANNATH HOSPITAL Tavz0r8 T SURAT ovalfoose ° [ANAND HOSPITAL, SURAT Daroi7e0T avatra019 ° VENUS HOSPITAL, SURAT ovorzaove oxaivzot9 ° ° ° ° mR alliancept.org