Northern California LEND Application 2023-2024

Secondary / Permanent Email

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

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

County of Origin (enter the county you relocated from, if different from your current county of residence)

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

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

Biological Sex
(per Federal Reporting requirements)

Gender

If you selected "Other" for #24 or #25 above, please specify here:

Race (check all that apply)

United States Residency Status

Due to HRSA federal funding, we are restricted in accepting trainees who have permanent resident or UC citizenship.

UC Davis / UC Davis Health Affiliation(s):

(check all the apply)

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

Do you speak a language other than English at home?

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?

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

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. 

If yes, what accommodations do you require?

(check all that apply)

If accepted into the LEND program, you will be required to follow UC Davis Health mandates for health clearance, including COVID and flu vaccinations and a background clearance. Please select one of the 2 statements:

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

Highest Academic Degree/Credential achieved

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

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

(if applicable) Position in Degree Program

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

Discipline

(Check all that apply)

If more than one discipline is selected in #56, which of the ones you selected is your primary discipline?

(write "n/a" if you did not select more than one discipline in #56)

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

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

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.

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)

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)

For Graduate or Postgraduate applicants only (family and self- advocates do not need to submit this):

Please submit an example of communication skills either via a written document, a video, or audio recording of an oral presentation, discussion, or interview.

(if applicable) Upload other file not specified in application