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The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

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Required format:

LEND Application 2022-23

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

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Gender

* must provide value

Male

Female

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Gender Identity (if not accurately captured above)

United States Residency Status

* must provide value

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

Yes

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If yes, please indicate what type of trainee.

Short-term

Medium-term

Medium-term Advanced

Long-term

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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: 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.

More than one race: includes individuals who identify with two or more racial designations.

Unable to identify with any of the above categories.

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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

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Do you speak a language other than English?

* must provide value

Yes. Spanish

Yes. Another language

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

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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.

* 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

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

* must provide value

N/A - Non-degree seeking

High School

Undergraduate

Masters

Doctoral

Postdoctoral

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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

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If yes, who is your advisor?

Are you currently employed?

Yes

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If yes, what is your current place of employment?

What is your current position/title?

Discipline (Check all that apply)

* must provide value

Audiology

Dentistry

Disability Studies

Education: General/Special Education

Family Studies

Family/Parent/Youth Advocacy

Family/Community Member

Genetics/Genetics Counseling

Health Administration

Human Development/Child Development

Medicine: General/Neurodevelopmental Disabilities

Mental and Behavioral Health

Nursing

Nutrition

Occupational Therapy

Pastoral

Person With a Disability* (refer to Q33 for definitions)

Pharmacy

Psychiatry

Psychology

Public Administration

Public Health

Rehabilitation

Social Work

Speech-Language Pathology

Other discipline, if not included in Question 43

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)

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

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Letter of Recommendation #2

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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

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Upload Other File Not Specified in Application (if applicable)

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