Northern California LEND Application 2024-2025

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Due Dates: All applications CLOSE on March 15th 2024 for the 2024-2025 training year, except for the LEND Speech Language Clinical Fellowship application which is due on May 27th 2024.

How to save your application: Please select the "Returning" button at the top right of the application BEFORE you enter any information. This will allow you to save your information and return to it so that you can complete this application in multiple sittings. Once you select "Returning", follow the instructions and use the code provided to return to your original application.

First Name

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Last Name

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Pronouns
Please share your pronouns

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she/her

he/him

they/them

she/they

he/they

ze/zir

other

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If you selected "other" above, please specify here:

Title
Please select your preferred title

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Mr.

Mrs.

Ms.

Mx.

Dr.

First name

Other

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Primary / Current Email

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Secondary / Permanent Email

(*enter at least one email address n̲o̲t̲ affiliated with a school or university, here or above)

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Phone Number
(please use format (999) 999-9999)

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Phone Type

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Address Line 1

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Address Line 2

City

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State

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Zip/Postal Code

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US County of Origin (examples: El Dorado, Placer, Sacramento, Yolo)

California Resident
Will you be residing in California for the LEND Year (September 2024-June 2025)

Please note that all LEND trainees must reside in California for the duration of the LEND year

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Yes

Unsure

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Name of Permanent Contact

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Permanent Contact's Relationship to You

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Permanent Address Line 1

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Permanent Address Line 2

City

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State

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Country

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Zip/Postal Code

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Phone
(Please use format: (999) 999-9999)

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Background Information:

LEND strives to include trainees from diverse backgrounds to promote community and a rich learning experience. Our goal is to better understand the needs and concerns of our applicants so that we can plan to provide the resources that each invited trainee needs to thrive within LEND. This information also illustrates who our program reaches and informs our ongoing efforts to increase inclusivity by expanding our outreach to a wide range of under-resourced and underrepresented populations.

Date of Birth
(Please use format: mm-dd-yyyy)

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M-D-Y

Social Security Number
(Please use format XXX-XX-XXXX)

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Will you be at least 22 years of age at the start of the LEND training program?

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Yes

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Biological Sex
(per Federal Reporting requirements)

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Male

Female

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Gender

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Male

Female

Transgender Woman/Trans Woman

Transgender Man/Trans Man

Gender Non-binary

Other

Prefer not to respond

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Sexual Orientation
Which of the following best represents how you think of yourself?

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Lesbian or Gay

Straight, that is, not gay or lesbian

Bisexual

Two-Spirit* (may apply if American Indian or Alaska Native)

Don't know

Prefer not to answer

Other

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If you selected "Other" for #30 or #31 above, please specify here:

Race (check all that apply)

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White: refers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black or African American: refers to people having origins in any of the Black racial groups of Africa.

American Indian and Alaskan Native: refers to people having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Asian: refers to people having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent (e.g. Asian Indian).

Native Hawaiian and Other Pacific Islander: refers to people having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Unable to identify with any of the above categories.

Ethnicity

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Hispanic (People whose origins are in the Spanish-speaking countries of Latin America or who identify with a Spanish-speaking culture. Individuals who are Hispanic may be of any race.)

Non-Hispanic

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United States Residency Status

Due to HRSA federal funding, we are restricted to accepting trainees who have permanent residence or US citizenship.

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I have been a LEND trainee at another program in the past.

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Yes

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If yes to #36, please indicate what type of trainee:

Short-term

Medium-term

Medium-term, Advanced

Long-term

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If yes to #36, at what LEND site were you a trainee?

UC Davis / UC Davis Health Affiliation(s):

(check all the apply)

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Current UC Davis / UC Davis Health student

Current UC Davis / UC Davis Health employee

Past UC Davis / UC Davis Health student

Past UC Davis / UC Davis Health employee

Current UC Davis / UC Davis Health volunteer

Past UC Davis / UC Davis Health volunteer

Other University of CA affiliation, other than UC Davis

None of the above (not applicable)

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If you do have an affiliation with the UC system (past or current), please provide your UC email (past or current) here:

UC Davis Employee Requirements

If accepted into the LEND program, you will be required to follow UC Davis Health Employee mandates for health clearance, including COVID and flu vaccinations and a background clearance. These and other onboarding requirements through UC Davis Health typically take about 9 hours in total and are non-optional. Please select one of the 2 statements:

(Additional information regarding these requirements will be made available before the start of the program.)

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I understand that if I participate as a trainee in the LEND program, I will need to follow the UC Davis Health mandates for health and background clearances and all other onboarding requirements.

I have questions/concerns about the UC Davis Health mandates for health and background clearances or onboarding requirements and would like to speak to someone from the LEND staff prior to completing my application (Please email hs-lend@ucdavis.edu).

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Do you speak a language other than English at home?

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Yes, Spanish

Yes, another language

If you speak a language other than Spanish and English at home, what is the language(s)?

Are you able to write in a language other than English?

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Yes, Spanish

Yes, another language

If you are able to write a language other than Spanish and English, what is the language(s)?

If English is not your primary language, how well do you speak English?

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Very well

Well

Not well

Not at all

N/A - English is my primary language

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Are you a... (Check all that apply)

"Disability" refers to a diverse group of severe chronic conditions that are due to mental and/or physical impairments that substantially restricts functioning in several major life activities. Examples include autism spectrum disorders, fetal alcohol syndrome, behavior disorders, Down syndrome, brain injury, fragile X syndrome, cerebral palsy, intellectual disabilities, and spina bifida.

"Special health care needs" can include physical, intellectual, and developmental disabilities, as well as long-standing medical conditions, such as asthma, diabetes, a blood disorder, or muscular dystrophy.

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Person with a disability

Person with a special health care need

Parent of a person with a disability

Parent of a person with a special health care need

Family member of a person with a disability

Family member of a person with a special health care need

None of the above

If accepted into the LEND program, will you require any special accommodations?

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Yes

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If yes, what accommodations do you require?

(check all that apply)

Accessible transportation

Adaptive equipment

Personal assistant

American Sign Language (ASL)

Augmentative & Alternative Communication Devices

Other

If you require other/additional accommodations, please describe what you will need:

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Current health coverage:

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Medi-Cal

Medicare

Private insurance (e.g., Blue Cross, Kaiser, etc.)

No insurance / Pay out-of-pocket

Highest Academic Degree/Credential achieved

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If you selected "Other" for #52, please specify here:

Current Enrollment Status

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Full-time Student

Part-time Student

Not currently a student

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Current Academic Level (Current enrollment status, not highest degree earned)

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N/A - Non-degree seeking

Undergraduate

Masters

Doctoral

Postdoctoral

Other

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Academic Degree Program for which you are currently enrolled (e.g., MA, MSW, PhD, or "N/A", if not currently a student)

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(if applicable) Position in Degree Program

(if applicable) Expected Completion/Graduation Date from degree program

Are you currently employed?

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Yes

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If yes, what is your current place of employment?

If yes, what is your current position/title?

Discipline

(Check all that apply)

Your Discipline is your background, your academic area of study, or the primary focus of your work or interest. For example, if you are a neurodivergent person studying psychology, then you would select "Person With a Disability" AND "Psychology" for question 60. Then for question 62 ("Primary Discipline") you would select ONE of these disciplines in the area you would like to receive mentoring from.

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Audiology

Disability Studies

Education: General

Education: Special Education

Family Studies

Family/Parent/Youth Advocacy

Family/Community Member

Genetics/Genetics Counseling

Health Administration

Human Development/Child Development

Medicine: General

Medicine: Developmental-Behavioral Pediatrics

Medicine: Other (specify in #63 below)

Mental and Behavioral Health

Nursing: General

Nursing: Other (specify in #63 below)

Nutrition

Occupational Therapy

Person With a Disability* (refer to Question #47 for definitions)

Physical Therapy

Psychiatry

Psychology

Public Administration

Public Health

Rehabilitation

Social Work

Speech-Language Pathology

OTHER discipline (none of the above)

If you selected "OTHER discipline" above, please list your discipline here:

(write "n/a" if you did not select "OTHER discipline" in #62)

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If more than one discipline is selected in #62, which of the ones you selected is your primary discipline?

(write "n/a" if you did not select more than one discipline in #62)

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Which LEND trainee track(s) are you interested in? (Check one or more)

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Long-term Trainee, Full-Time Stipend (paid stipend, 40 hours/week, 2000+ hours of training upon completion) - Psychology Postdoc & SLP Clinical Fellow Positions ONLY

Long-term Trainee, Stipend (paid stipend, 500+ hours of training upon completion)

Long-term Trainee, Unpaid (upaid, 300+ hours of training upon completion)

Medium-term Trainee, Advanced (unpaid, 150-299 hours of training upon completion)

Medium-term Trainee (unpaid, 40-149 hours of training upon completion)

Do you currently have a Faculty or Family advisor affiliated with the LEND?

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Yes

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If yes, who is your advisor?

How did you hear about the LEND program? (e.g., MIND website, Facebook, department listserv, etc.)

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Letter of Interest:

Please explain your interest in the LEND program, professional and/or personal experiences with ASD/NDD, any interest in working with diverse populations, and career goals. If you identify with an underrepresented group, describe how you have built a community of support and how can we help you continue to build that support here at UCD.

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Curriculum Vitae or Resume

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Letter of Recommendation #1

(*If your letter provider would prefer to send their letter separately, please have them email it to hs-lend@ucdavis.edu)

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Letter of Recommendation #2

(*If your letter provider would prefer to send their letter separately, please have them email it to hs-lend@ucdavis.edu)

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Communication Sample

If you have a bachelor's degree or higher, please submit an example of your communication skills. This could be a writing sample (such as a college essay), a video, or audio recording of an oral presentation, discussion, or interview.

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(Optional) Upload other file not specified in application

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