<p> RESIDENCY APPLICATION</p><p>Mailing Address:</p><p>USC Division of Biokinesiology & Physical Therapy Admissions Office 1540 Alcazar Street, CHP 155 Los Angeles, California 90089-9006</p><p>Applicant Information</p><p>Male Legal Name ______Female Last First Middle</p><p>Date of Birth: ______</p><p>Current Address: From ______To ______mm/yyyy mm/yyyy ______Number and Street Apt. City State Zip Code</p><p>Permanent home address: ______Number and Street Apt. City State Zip Code</p><p>Permanent Home Telephone(______) ______Cell Phone (______) ______</p><p>E-mail Address ______</p><p>PROGRAMS: APPLICATION DEADLINE: ADMITTING SEMESTER: Ortho. Residency April 1st Fall Semester Pediatric Residency March 1st Fall Semester Neuro. Residency April 1st Fall Semester. st Sport Residency April 1 Fall Semester </p><p>PROGRAMS: TERM: 8. Select the program you are applying to: Fall 201______</p><p> Certificate in Orthopedic Physical Therapy Residency </p><p> Certificate in Pediatric Physical Therapy Residency </p><p> Certificate in Neurologic Physical Therapy Residency </p><p> Certificate in Sports Physical Therapy Residency</p><p>I certify that the information on the Division Application is correct to the best of my knowledge.</p><p>Signature of Applicant: ______Date: ______</p><p>EDUCATIONAL BACKGROUND:</p><p>9. What is your highest academic degree?______</p><p>10. If you have completed a Master’s degree, was an independent research project required?  Yes  No</p><p>If yes , please state the title of your research project:______</p><p>Are you currently licensed to practice physical therapy in the State of California?  Yes  No</p><p>Are you eligible for licensure in State of California?  Yes  No</p><p>Are you board certified in a clinical specialty?  Yes  No</p><p>If yes, give the specialty and date of certification:</p><p>______</p><p>______</p><p>Additional questions for Sports Residency Applicants only:</p><p>What is your emergency response credential?  Certified Athletic Trainer  Licensed EMT  Certified Emergency Responder</p><p>If you do not currently have an emergency response credential, when are you scheduled to take the Certified Emergency Responder course? ______</p><p>11. COLLEGES/UNIVERSITY ATTENDED:</p><p>Name of Colleges Attended Year(s) Degree or Certificate Major Graduate Date Attended</p><p>12. WORK EXPERIENCE:</p><p>List the three (3) most recent positions you have held:</p><p>Position (Title) Employer Dates</p><p>______</p><p>______</p><p>______</p><p>2 of 4</p><p>CAREER STATEMENT: The career statement should be typed and double-spaced. Please use the following questions for guidance, as they relate to your clinical/academic circumstance, to assist in the preparation of your career statement please consider:</p><p>1. What are your professional goals or objectives? 2. How do you plan to accomplish these goals and how will the USC residency assist your achievement? 3. By achievement of your professional goals, what do you believe that you will contribute to the field of physical therapy? 4. What is the area of your current research or clinical interest? 5. Compile a description of your clinical experience as a physical therapist (if applicable.)</p><p>For Applicants to the Pediatric Residency (only)</p><p>6. Describe how you have demonstrated leadership in the past (either personally or professionally). 7. How will involvement in the CA-LEND training program help you achieve your professional goals? Include information about your experience or work (if any) with children, families and persons with neurodevelopmental disabilities, including the diagnosis of autism spectrum disorder, or chronic health conditions. Include special areas of interest. </p><p>LETTERS OF RECOMMENDATION: Please give the enclosed letter of recommendation forms to individuals who would be willing to comment on your abilities. The letters of recommendation should be returned to you in a sealed envelope and sent with your Division Application packet. We strongly suggest that you include individuals who are able to comment on your academic and your clinical research capabilities or potentials. </p><p>Number of recommendation letters required for the following programs: Three ( 3 ) required for all Residency Programs</p><p>Please list the names and address of the individuals to whom you have sent the recommendation forms. </p><p>Name Address/City/State (Area Code) Telephone No.</p><p>3 of 4</p><p>REQUEST FOR LETTER OF RECOMMENDATION</p><p>Mailing Address: University of Southern California Division of Biokinesiology & Physical Therapy Admissions Office 1540 Alcazar Street, CHP 155 Los Angeles, CA 90089-9006</p><p>Applicant’s Name ______</p><p>To the Applicant: I understand that under provisions of the Family Education Rights and Privacy Act of l974, I have access to my letters of recommendation. I expressly Do or Do Not (circle one) wish to waive my access to this letter. I understand that a wavier of access to my file is NOT required as condition for admission, receipt of financial aid or any other services or benefits.</p><p>______/______Applicant’s Signature Date</p><p>To the Evaluator: Please write a letter on your Professional Letterhead evaluating the applicant in comparison with his/her clinical and/or academic peers. Your letter should be an evaluation of the candidate’s overall potential for a professional contribution. If possible, include your knowledge of the applicant’s academic abilities (e.g., comprehension, retention, abstract reasoning, perseverance, independence), communication skills (e.g., written, verbal, interpersonal); and personal and professional development (e.g., self-concept, integrity, peer relationship, empathy).</p><p>______</p><p>For Applicants to the Pediatric Residency (only)</p><p>The pediatric resident will participate in many clinical activities including the CA-LEND program (see description at the end of this document). Please provide your estimate of the applicant’s ability to pursue and to complete an inter-disciplinary leadership training curriculum in Maternal and Child Health/Neurodevelopmental Disabilities. Rate the applicant on the following achievements and characteristics Excellent Above Average Below Unable to Average Average Judge Clinical Knowledge and Skills Academic Knowledge and Abilities Ability to express himself/herself in speech and writing Self reliance and independence Maturity Flexibility Cultural sensitivity Ability to work with others who have different viewpoints Reliability and follow-through Leadership potential The California Leadership Education in Neurodevelopmental Disabilities (CA-LEND) education program is located within the Children’s Hospital of Los Angeles (CHLA). CA- LEND uses Life Course as the primary framework, along with Maternal and Child Health (MCH) values, to educate the next generation of interdisciplinary MCH leaders and workforce in healthcare to have the necessary skills and experience for shaping appropriate and effective health policies, programs, and outcomes for children/youth with Neurodevelopmental and Other Disabilities, including Autism Spectrum Disorder and special health care needs. Our graduates will have competencies at the 4 levels of core public health services for the MCH population: (1) Infrastructure Building (2) Population Based Services; (3) Enabling Services and (4) Direct Health Care Services. Graduates will be able to provide and ensure high-quality, cost-effective, community-based integrated services in the communities they work in within a coordinated, culturally competent, family-centered orientation. They will also develop skills to effect systems change through research, policy and inter-agency collaborations, particularly with Title V agencies and to cultivate interdisciplinary practice and research in new settings, including those which emphasize primary care or uni-disciplinary or multidisciplinary methods. A special focus is on unserved and underserved populations, which already includes the majority of families seen at CHLA and our community-based partnerships.</p><p>______</p><p>Please identify your relationship with applicant:</p><p> Professor  Research Advisor  Clinical Supervisor  Relative  Friend/Colleague</p><p>______Evaluator’s Name & Title </p><p>______Evaluator’s Signature / Date </p><p>______Facility/ University</p><p>______email:______(Area code) Telephone No./ Extension </p><p>Please return this form and letter of recommendation in a sealed envelope to the Applicant. If you prefer to send the letter directly to the Division of Biokinesiology & Physical Therapy, please send to the mailing address above. </p><p>APPLICATION PROCEDURES:</p><p>Please submit the following documents in One Packet to USC Biokinesiology & Physical Therapy Division.</p><p> Application Fee $85.00 made payable to: USC PT  Official transcripts from each college or university attended (Transcripts must be in a sealed envelope).  Career Statement  Current curriculum vitae  Letters of Recommendation. Letter of recommendation must be in a sealed envelope. (Evaluators may send letters of recommendation directly to the program)</p><p>Applicants are required to have a personal interview. You will be notified at a later date regarding the interview. If you have any questions regarding the Division Application, please contact Virginia Orcasitas, Admission Coordinator, at (323) 442-2890. If you have questions regarding the programs, contact the following Directors:</p><p>Director of Neurologic Residency: Beth Fisher, PT, PhD at: [email protected] or (323) 442-2796</p><p>Director for Orthopedic Residency: Mike O’Donnell, PT, DPT, OCS, FAAOMPT at: [email protected] or (310) 547-1850</p><p>Director of Pediatric Residency: Linda Fetters, PT, PhD, FAPTA at: [email protected] or (323) 442-1022</p><p>Director of Sports Residency: Aimee Diaz, PT, DPT, SCS, ATC at: [email protected] or (323) 224-7070</p>