RESIDENCY APPLICATION
Mailing Address:
USC Division of Biokinesiology & Physical Therapy
Admissions Office
1540 Alcazar Street, CHP 155
Los Angeles, California 90089-9006
Applicant Information
Male
Legal Name ____________________________________________________________________________________________
Last
First
Female
Middle
Date of Birth: _____________________
Current Address: From _____________
To _____________
mm/yyyy
mm/yyyy
________________________________________________________________________________________________________________
Number and Street
Apt.
City
State
Zip Code
Permanent home address: _____________________________________________________________________________________
Number and Street
Apt.
City
State
Zip Code
Permanent Home Telephone(________) ____________________Cell Phone (________) ___________________________________
E-mail Address ___________________________________________
PROGRAMS:
APPLICATION DEADLINE:
ADMITTING SEMESTER:
Ortho. Residency
Pediatric Residency
Neuro. Residency
Sport Residency
April 1st
March 1st
April 1st
April 1st
Fall Semester
Fall Semester
Fall Semester.
Fall Semester
PROGRAMS:
8.
TERM:
Select the program you are applying to:

Certificate in Orthopedic Physical Therapy Residency

Certificate in Pediatric Physical Therapy Residency

Certificate in Neurologic Physical Therapy Residency

Certificate in Sports Physical Therapy Residency
Fall 201________
I certify that the information on the Division Application is correct to the best of my knowledge.
Signature of Applicant: ________________________________________ Date: _________________________
EDUCATIONAL BACKGROUND:
9.
What is your highest academic degree?____________________________________________________________
10. If you have completed a Master’s degree, was an independent research project required?
 Yes
 No
If yes , please state the title of your research project:__________________________________________________
Are you currently licensed to practice physical therapy in the State of California?
 Yes
 No
Are you eligible for licensure in State of California?
 Yes
 No
Are you board certified in a clinical specialty?
 Yes
 No
If yes, give the specialty and date of certification:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Additional questions for Sports Residency Applicants only:
What is your emergency response credential?
 Certified Athletic Trainer
 Licensed EMT
 Certified Emergency Responder
If you do not currently have an emergency response credential, when are you scheduled to take the Certified Emergency
Responder course? ___________________________
11. COLLEGES/UNIVERSITY
Name of Colleges Attended
12.
ATTENDED:
Year(s)
Attended
Degree or Certificate
Major
Graduate Date
WORK EXPERIENCE:
List the three (3) most recent positions you have held:
Position (Title)
Employer
Dates
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
2 of 4
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:
1.
2.
What are your professional goals or objectives?
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.)
For Applicants to the Pediatric Residency (only)
6.
7.
Describe how you have demonstrated leadership in the past (either personally or
professionally).
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.
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.
Number of recommendation letters required for the following programs:
Three ( 3 ) required for all Residency Programs
Please list the names and address of the individuals to whom you have sent the recommendation forms.
Name
Address/City/State
(Area Code) Telephone No.
3 of 4
REQUEST FOR LETTER OF RECOMMENDATION
Mailing Address:
University of Southern California
Division of Biokinesiology & Physical Therapy
Admissions Office
1540 Alcazar Street, CHP 155
Los Angeles, CA 90089-9006
Applicant’s Name______________________________________________________________________
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.
_____________________________________________/_____________________________________
Applicant’s Signature
Date
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).
_____________________________________________________________________________________
For Applicants to the Pediatric Residency (only)
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
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
Above
Average
Average
Below
Average
Unable to
Judge
The California Leadership Education in Neurodevelopmental Disabilities (CA-LEND)
education program is located within the Children’s Hospital of Los Angeles (CHLA). CALEND 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.
_____________________________________________________________________________________
Please identify your relationship with applicant:





Professor
Research Advisor
Clinical Supervisor
Relative
Friend/Colleague
_____________________________________________________________________________________
Evaluator’s Name & Title
_____________________________________________________________________________________
Evaluator’s Signature
/ Date
_____________________________________________________________________________________
Facility/ University
_______________________________________email:___________________________________________
(Area code) Telephone No./ Extension
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.
APPLICATION PROCEDURES:
Please submit the following documents in One Packet to USC Biokinesiology & Physical Therapy Division.





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)
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:
Director of Neurologic Residency:
Beth Fisher, PT, PhD at: bfisher@usc.edu or (323) 442-2796
Director for Orthopedic Residency:
Mike O’Donnell, PT, DPT, OCS, FAAOMPT at: modonnell@usc.edu or (310) 547-1850
Director of Pediatric Residency:
Linda Fetters, PT, PhD, FAPTA at: fetters@usc.edu or (323) 442-1022
Director of Sports Residency:
Aimee Diaz, PT, DPT, SCS, ATC at: aimeedia@usc.edu or (323) 224-7070