Athletic Training Form 2 - Certification Of Professional Education Page 2
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2Section II: Certification of Professional Education
INSTRUCTIONS TO INSTITUTION REGISTRAR: Complete either Part A or Part B to document the applicant’s education. Complete Part C
(Certification) and return both pages of this form in an official school envelope directly to the Office of the Professions at the address at the end
of the form. Do not return this form to the applicant. This form will not be accepted if returned by the applicant.
Name of applicant: ____________________________________________________________________________________________________________
(Section I, item 5)
Part A – Athletic Training programs registered by the New York State Education Department (NYSED) as licensure qualifying or
accredited by the National Athletic Trainers’ Association (NATA), by the Commission on Accreditation of Allied Health Programs
(CAAHP) or by the Commission on Accreditation of Athletic Training Education (CAATE).
To be completed only by those schools at which the applicant completed an athletic training program which was either registered by NYSED
as licensure qualifying or accredited by NATA, CAAHP or by the CAATE at the time the applicant completed the program.
It is hereby certified that: ____________________________________________________________________________________________________
was awarded the degree of _____________________________________________________________ on the date of _______ / _______ / _______,
mo.
day
yr.
and the curriculum completed at the time the degree was awarded was registered by the NYSED as licensure qualifying or was accredited in athletic
training by the NATA, CAAHP or the CAATE.
The program title was: _____________________________________________________________________________________________________.
Part B – All other programs. An official transcript or marksheet giving courses completed by year and grades and a syllabus of
the course of studies completed must be attached.
(1)
Date of applicant's entrance, and either the applicant’s date of completion of studies or withdrawal from the school:
Entrance Date: ______ / ______ / ______
Completion Date: ______ / ______ / ______
Withdrawal date ______ / ______ / ______
mo.
day
yr.
mo.
day
yr.
mo.
day
yr.
(2)
Clock hours of athletic training practicum completed by applicant: ___________________________
(3)
Degree awarded: _____________________________________________________________________________________________________
(4)
Date degree awarded: ______ / ______ / ______
mo.
day
yr.
Name of accrediting body or official organization that recognizes this program: _____________________________________________________
Date of accreditation ______________
year
Address of accrediting body or official organization that recognizes this program: ___________________________________________________
___________________________________________________________________________________________________________________
PART C – REGISTRAR’S CERTIFICATION
I hereby certify that to the best of my knowledge and belief the information in Section II is a true and accurate statement of the educational
record of the individual named on this form.
Signature of Registrar _______________________________________________________ Date _______ / _______ / _______
mo.
day
yr.
Print name ________________________________________________________________
Title or Official Position ______________________________________________________
Institution _________________________________________________________________
Address __________________________________________________________________
INSTITUTION SEAL
__________________________________________________________________
Telephone ____________________________ Fax ________________________________
E-Mail ____________________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Athletic Trainer Unit, 89
Washington Avenue, Albany, NY 12234-1000.
Athletic Trainer Form 2, Page 2 of 2, (Rev. 08/06)
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