University of Southern California

Minority Health International Research Training (MHIRT)

Latino Mental Health Program
Summer 2011 in Mexico
Application Due Date: Tuesday, February 1, 2011

CONTACT/PERSONAL INFORMATION

First Name ____________________________ Last Name ________________________________ Middle Initial _______

Primary e-mail _____________________________________ Alternate e-mail __________________________________

Home phone number ________________________________ Cell phone number _______________________________

Date of birth mm/dd/yy _______________ ___ Male ___ Female Marital Status ____________________

N/A
Are you a U.S. citizen or non-citizen national? ____ N/A
If not, are you a permanent resident? ____

Ethnicity

__ Latino/Hispanic/Chicano __ African American/Black __ American Indian/Alaskan Native

__ Native Hawaiian/Pacific Islander/Asian American __ Other _____________________________________

Current mailing address

Street address ____________________________________________________________________________________

City, State, Zip ____________________________________________________________________________________

Permanent mailing address

Street address ____________________________________________________________________________________

City, State, Zip ____________________________________________________________________________________

Current mailing address
Permanent phone number _______________________________ Preferred contact method _______________________

Emergency contact information

Name of emergency contact _________________________________________________________________________

Address, City, State, Zip ____________________________________________________________________________

Relationship to applicant _________________________________ E-mail _____________________________________

Primary phone number _____________________________ Alternate Phone number ____________________________

ACADEMIC INFORMATION

Junior
Year in school/Current status _____________________________

Name of Institution (current or last attended) _________________________________________________________________

Major/field of study ____________________ Minor ____________________

(Anticipated) graduation date (mm/yy) __________ Overall GPA __________ Psychology GPA (If applicable) _________


 
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Undergraduate Transfer Students and Graduate Students (only) - Please provide information for previous school attended

Name of institution _________________________________________________________________________________

Major/field of study ________________________ Overall GPA _________ Psychology GPA (If applicable) ___________

ADDITIONAL INFORMATION

Were/are you a member of any one of the following programs? If so, when?
(Y/N) (Example: mm/yy -- present)
a. Bridges to the Future Program _____
No _________________
b. Minority Access to Research Careers (MARC) _____
No _________________
c. Alliance for Minority Participation (AMP) _____
No _________________
d. McNair Program No
_____ _________________

Preference for training project

___ La CLAve Project ___ Family and Schizophrenia Project ___ Disability Project ___ Family Caregiving

Please explain briefly the reasoning for your preference _____________________________________________

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Letters of Recommendation

Names of people providing letters on your behalf

(1) _____________________________________________ (2) ______________________________________________

SUPPORTING APPLICATION MATERIALS

Essay

In the following section of this application, please type or paste your essay in the space provided (Pages 4 and 5 of 9).
Please make sure that your entire essay is visible across the pages when pasting in the designated area. The essay
should be no more than 1,250 words (approximately 2 single-spaced Word pages) in 12 point Times New Roman font.

In the essay, please (1) provide your rationale for applying to the program, (2) describe your long-term professional goals,
and (3) discuss your specific research interests.

Resume/CV

Please type or paste your resume or CV in the space provided (Pages 6-8 of 9). Please be sure to include a list of any
publications or presentations that you have done. Use as much space as needed, leaving any remaining space blank.

I certify that all information provided in this application form and in any related material is complete and accurate.

Electronic signature ________________________________________________________ Date __________________

(Please print full name)


 
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ENGLISH AND SPANISH LANGUAGE SKILLS

Bidimensional Acculturation Scale (Marín & Gamba, 1996)

Language Use: Almost Always = 4 Often = 3 Sometimes = 2 Never = 1

1. How often do you speak English? _____

2. How often do you speak in English with your friends? _____

3. How often do you think in English? _____

4. How often do you speak Spanish? _____

5. How often do you speak in Spanish with your friends? _____

6. How often do you think in Spanish? _____

Linguistic Proficiency: Very Well = 4 Well = 3 Poorly = 2 Poor = 1

7. How well do you speak English? _____

8. How well do you read in English?

 
 
 
 _____


9. How well do you understand television programs in English?
_____


10. How well do you understand radio programs in English?

 _____


11. How well do you write in English?

 
 
 
 _____


12. How well do you understand music in English?

 
 _____


13. How well do you speak Spanish?

 
 
 
 _____


14. How well do you read in Spanish?

 
 
 
 _____


15. How well do you understand television programs in Spanish?_____


16. How well do you understand radio programs in Spanish?

 _____


17. How well do you write in Spanish?

 
 
 
 _____


18. How well do you understand music in Spanish?

 
 _____


Electronic Media: Almost Always = 4 Often = 3 Sometimes = 2 Never = 1

19. How often do you watch television programs in English?

 _____


20. How often do you listen to radio programs in English?

 _____


21. How often do you listen to music in English?

 
 _____


22. How often do you watch television programs in Spanish? _____


23. How often do you listen to radio programs in Spanish?

 _____


24. How often do you listen to music in Spanish?

 
 _____



 
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ESSAY


 
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RESUME/CV


 
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FINAL APPLICATION CHECKLIST & INSTRUCTIONS

To be submitted electronically (required)

1. PROGRAM APPLICATION
Please verify that you have completed all required sections of this application.

2. ESSAY

3. RESUME or CV

To be submitted electronically (preferred) or via post mail

4. LETTERS OF RECOMMENDATION
Please include letters from two faculty members who can speak about your aptitude and experience. Letters from
faculty who carry out research in the sciences is preferable.

5. TRANSCRIPTS
Please provide transcripts, official or unofficial, from school(s) attended. Transfer students; submit transcripts from both
transferring and current institutions. Graduate students; provide both undergraduate and graduate transcripts. If
providing unofficial transcripts, please keep in mind that you will need to provide official transcripts if accepted into the
program. If possible, please submit transcripts electronically.

All application materials must be received by Tuesday, February 1, 2011.

SUBMIT ALL ELECTRONIC MATERIALS TO:

btvillal@usc.edu

SUBMIT ALL PAPER MATERIALS TO:

Bianca Villalobos, MHIRT Project Assistant
University of Southern California
Psychology Department
3620 McClintock Avenue
Los Angeles, CA 90089


 
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