UW LEND Application

Instructions:

• Prepare and gather all required application documents, have these ready to upload

• Complete the application form by typing in your responses below

• Upload documents

• Upload your Personal References or request the individuals completing the Recommendation Form to email them directly to lend@uw.edu (instructions on form)

• Press Submit to turn in you completed application

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.

First Name*:

Last Name*:

Date of Birth*:

Place of Birth:

Your Email*:

Personal Email:

Mobile Phone*:

Mailing Address

Address Line 1*:

Address Line 2:

City*:

State/Province*:

Zip/Postal Code*:

Preferred Primary LEND Trainee Discipline*:

Please choose a discipline Audiology ABA Dentistry Pediatric Medicine Adult Medicine Family Genetics Medical Interpreter Nursing/ARNP Occupational Therapy Physical Therapy Psychology Public Health School Psychology Self-Advocate Social Work Special Education Speech Language Pathology Other

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*: Select a Gender Gender non conforming Genderqueer Man Non-binary Woman Other

Pronoun*: Select a Pronoun She/her/hers He/him/his She/They He/They Other Prefer not to say

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.

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*:

—Please choose an option— AA ARNP BA BS DDS DO MA MD MPH MS PhD Clinical Doctorate N/A I am a family or self-advocate

Degree Working Toward (if applicable):

—Please choose an option— AA ARNP BA BS DDS DO MA MD MPH MS PhD Clinical Doctorate

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)