UW LEND Application

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Required Documents for Your Application:

Your responses to demographic information (see below)
Personal Statement (PDF): Please complete this form
Copy of resume or CV
Two references (your references complete this Recommendation Form)

For assistance completing the application materials, please contact nan Ringera, Administrative Assistant. We want to assure your success with this process - please do not hesitate to contact us for help.
All fields with (*) are required
First Name*:	Last Name*:
Date of Birth*:	Place of Birth*:
Preferred Email*:	Other Email:
Mobile Phone*:
Mailing Address
Address Line 1*:	Address Line 2:
City*:	State/Province*:
Zip/Postal Code*:
*Preferred Primary LEND Trainee Discipline:**

Demographic Information Why are we collecting this information?: The UW LEND mission is to build a future healthcare workforce of clinicians, educators, and family and self-advocate leaders who represent the communities we serve. UW LEND is committed to bringing together learners from a variety of backgrounds and lived experiences. The information you provide in your application helps to ensure that we are accountable to the goals of our mission.
*Gender:**	*Pronoun:**
*Ethnicity/Race:** Please select all that apply American Indian/Alaskan NativeAsian – regional ancestry not specifiedCentral AsianEastern AsianSoutheastern AsianSouth AsianBlack – regional ancestry not specifiedBlack – African AmericanBlack – African CanadianBlack - East AfricanBlack – Latin AmericanBlack – West AfricanHispanic – Latina (a)(x) Mexico and Central AmericanHispanic – Latina (a)(x) CaribbeanHispanic – Latina (a)(x) South AmericanHispanic – Latina (a)(x) Spanish originHispanic – Latina (a)(x regional ancestry not specifiedMiddle EasternNative Hawaiian/Pacific IslanderNorth AfricanWhiteOtherPrefer not to say
*Languages Used (Fluent):**
*Are You a US Citizen:YesNo Note:** UW LEND can only offer training stipends to individuals who are US Citizens; we welcome all applicants; status of citizenship only affects eligibility for stipend.

Additional Information How would you describe your relationship to individuals with a developmental disability? (Check all that apply)
I have a developmental disabilityI have a special health care needI consider myself neurodiverseParent of a person with a developmental disabilityParent of a person with a special health care need	Family member of a person with a developmental disabilityFamily member of a person with a special health care needDoes not applyPrefer not to answerOther

Please upload your Personal Statement, Resume or CV, and two References.
Personal Statement* (Accepted file types: pdf, doc, docx, Max. file size: 2 MB)
Resume or CV* (Accepted file types: pdf, doc, docx, Max. file size: 2 MB)
Personal Reference #1 (Accepted file types: pdf, doc, docx, Max. file size: 2 MB)
Personal Reference #2 (Accepted file types: pdf, doc, docx, Max. file size: 2 MB)

For assistance completing the application materials, please contact nan Ringera, Administrative Assistant. We want to assure your success with this process - please do not hesitate to contact us for help.

All fields with (*) are required

First Name*:

Last Name*:

Date of Birth*:

Place of Birth*:

Preferred Email*:

Other Email:

Mobile Phone*:

Mailing Address

Address Line 1*:

Address Line 2:

City*:

State/Province*:

Zip/Postal Code*:

Preferred Primary LEND Trainee Discipline*:

Demographic Information

Why are we collecting this information?: The UW LEND mission is to build a future healthcare workforce of clinicians, educators, and family and self-advocate leaders who represent the communities we serve. UW LEND is committed to bringing together learners from a variety of backgrounds and lived experiences. The information you provide in your application helps to ensure that we are accountable to the goals of our mission.

Gender*:

Pronoun*:

Ethnicity/Race*:

Please select all that apply

American Indian/Alaskan NativeAsian – regional ancestry not specifiedCentral AsianEastern AsianSoutheastern AsianSouth AsianBlack – regional ancestry not specifiedBlack – African AmericanBlack – African CanadianBlack - East AfricanBlack – Latin AmericanBlack – West AfricanHispanic – Latina (a)(x) Mexico and Central AmericanHispanic – Latina (a)(x) CaribbeanHispanic – Latina (a)(x) South AmericanHispanic – Latina (a)(x) Spanish originHispanic – Latina (a)(x regional ancestry not specifiedMiddle EasternNative Hawaiian/Pacific IslanderNorth AfricanWhiteOtherPrefer not to say

Languages Used (Fluent)*:

Are You a US Citizen*:YesNo
Note: UW LEND can only offer training stipends to individuals who are US Citizens; we welcome all applicants; status of citizenship only affects eligibility for stipend.

Additional Information

How would you describe your relationship to individuals with a developmental disability? (Check all that apply)
I have a developmental disabilityI have a special health care needI consider myself neurodiverseParent of a person with a developmental disabilityParent of a person with a special health care needFamily member of a person with a developmental disabilityFamily member of a person with a special health care needDoes not applyPrefer not to answerOther

Please upload your Personal Statement, Resume or CV, and two References.

Personal Statement* (Accepted file types: pdf, doc, docx, Max. file size: 2 MB)

Resume or CV* (Accepted file types: pdf, doc, docx, Max. file size: 2 MB)

Personal Reference #1 (Accepted file types: pdf, doc, docx, Max. file size: 2 MB)

Personal Reference #2 (Accepted file types: pdf, doc, docx, Max. file size: 2 MB)

Leadership Education in Neurodevelopmental and Related Disabilities at the University of Washington

First Name*:	Last Name*:
Date of Birth*:	Place of Birth*:
Your Email*:	Alternate Email:
Mobile Phone*:
Mailing Address
Address Line 1*:	Address Line 2:
City and State/Province*:	Zip/Postal Code*:
*Preferred UW LEND Trainee Discipline:**

*Gender:**	*Preferred pronoun:**

To select multiple, please press and hold the control-key (PC) or command-key (Mac)
*Ethnicity/Race:**	*Languages Spoken:**
*Are You a US Citizen:YesNo Note:** UW LEND can only offer training stipends to individuals who are US Citizens; we welcome all applicants; status of citizenship only affects eligibility for stipend.

Academic Information
Please complete if you are a current/former University of Washington student/employee.
UW Student Number:
UW Employee ID:
UW NetID:
*Highest Degree Attained:**
Degree Sought (if applicable):

How would you describe your relationship to individuals with a developmental disability? To select multiple, hold control-key (PC) or command-key (Mac)

If you selected 'Other' above, please enter your information in the text box below:

Please upload your Personal Statement, Resume or CV, and two References.
Personal Statement* (Accepted file types: pdf, doc, docx, Max. file size: 2 MB)
Resume or CV* (Accepted file types: pdf, doc, docx, Max. file size: 2 MB)
Personal Reference #1 (Accepted file types: pdf, doc, docx, Max. file size: 2 MB)
Personal Reference #2 (Accepted file types: pdf, doc, docx, Max. file size: 2 MB)

UW LEND Application

The UW LEND mission is to build a future healthcare workforce of clinicians, educators, and family and self-advocate leaders who represent the communities we serve. UW LEND is committed to bringing together learners from a variety of backgrounds and lived experiences. The information you provide in your application helps to ensure that we are accountable to the goals of our mission.

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