First Name* must provide value
Last Name* must provide value
Primary email (Please enter at least one email address not affiliated with a school or university)* must provide value
Secondary email* must provide value
Phone Number * must provide value
Address Line 1* must provide value
Address Line 2* must provide value
City* must provide value
State* must provide value
Zip/Postal Code* must provide value
County of Origin (if within California)
Name of Permanent Contact* must provide value
Relationship to Permanent Contact* must provide value
Permanent Address Line 1* must provide value
Permanent Address Line 2* must provide value
City* must provide value
State* must provide value
Zip/Postal Code* must provide value
Phone * must provide value
Date of Birth* must provide value
Please confirm that you are at least 22 years of age Yes
No
Gender* must provide value
Male
Female
United States Residency Status US Citizen Permanent Resident Non-US Resident
I have been a LEND trainee at another program in the past. Yes
No
If yes, please indicate what type of trainee. Short-term
Medium-term
Medium-term Advanced
Long-term
If yes, at what LEND site were you a trainee?
Race
* must provide value
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 refer 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.
More than one race includes individuals who identify with two or more racial designations.
Unrecorded is included for individuals who are unable to identify with the categories.
Ethnicity* must provide value
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
Do you speak a language other than English?* must provide value
Yes. Spanish
Yes. Another language
No
If you speak a language other than Spanish and English, what is it?
How well do you speak English?* must provide value
Very well
Well
Not well
Not at all
N/A - English is my primary language
Are you a... (Check all that apply)* must provide value
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
Highest Academic Degree/Credential Achieved (e.g., BS, MD, PhD)
* must provide value
Current Enrollment Status* must provide value
Full-time Student
Part-time Student
Not currently a student
Academic Level (Current enrollment status, not highest degree earned)* must provide value
N/A - Non-degree seeking
High School
Undergraduate
Masters
Doctoral
Postdoctoral
Academic Degree Program for which you are currently enrolled (e.g., MA, MSW, EdD, PhD)* must provide value
Do you currently have a Faculty or Family advisor affiliated with the LEND? Yes
No
If yes, who is your advisor?
Are you currently employed? Yes
No
If yes, what is your current place of employment?
What is your current position/title?
Discipline (Check all that apply)* must provide value
Audiology
Biological Sciences
Dentistry-Pediatric
Dentistry-Other
Disability Studies
Education/Special Education
Education: Administration
Education: Early Intervention/Early Childhood
Education: General Education
Epidemiology
Family Studies
Family/Parent/Youth Advocacy
Family/Community Member
Genetics/Genetics Counseling
Gerontology
Health Administration
Human Development/Child Development
Interdisciplinary
Law
Liberal Arts & Sciences, Humanities, & General Studies
Medicine-Adolescent Medicine
Medicine-Developmental-Behavioral Pediatrics
Medicine-Neurodevelopmental Disabilities
Medicine-Pediatric Pulmonology
Medicine: General
Medicine: Pediatric
Medicine: Other
Mental and Behavioral Health
Nursing
Nursing-Family/Pediatric Nurse Practitioner
Nursing-Midwife
Nursing-Other
Nutrition
Occupational Therapy
Pastoral
Person With a Disability or Special Healthcare Need
Pharmacy
Physical Therapy
Psychiatry
Psychology
Public Administration
Public Health
Rehabilitation
Respiratory Therapy
Social Work
Speech-Language Pathology
Other discipline, if not included in Question 42
If more than one discipline is selected, which is your primary discipline?* must provide value
Which LEND trainee track(s) are you interested in? (Check one or more)* must provide value
Long-term Trainee, Unpaid (upaid, 300+ hours of training upon completion)
Long-term Trainee, Stipend (paid stipend, 500+ hours of training upon completion)
Long-term Trainee, Full-Time Stipend (paid stipend, 40 hours/week, 2000+ hours of training upon completion) - Psychological Postdoc & SLP Clinical Fellow Positions only
Medium-term Trainee, Advanced (unpaid, 150-299 hours of training upon completion)
Medium-term Trainee (unpaid, 40-149 hours of training upon completion)
Short-term Trainee (unpaid, <40 hours upon completion)
Letter of interest: Please include interest in Northern CA LEND program, professional and/or personal experience with ASD/NDD, any interest in working with diverse populations, and career goals.
Curriculum Vitae or resume
Letter of Recommendation #1
Letter of Recommendation #2
For Graduate or Postgraduate applicants only (family and self- advocates do not need to submit this): submit an example of communication skills either via a written document, a video, or audio recording of an oral presentation, discussion, or interview
Upload Other File Not Specified in Application