Thank you for applying to the KUMC Leadership Education in Neurodevelopmental Disabilities Program. Date of Application (M/D/Y)* must provide value
Today M-D-Y
Last Name* must provide value
First Name* must provide value
Middle Initial
List other names under which records may be obtained
Gender (per Federal Reporting requirements):* must provide value
Male
Female
Other
Gender Identity
Date of Birth* must provide value
Social Security Number (123-45-6789)* must provide value
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 or 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 or 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
Please specify tribe
What is your ethnicity? *Hispanic is an ethnic category for 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.
* must provide value
Hispanic
Non Hispanic
Unrecorded
Do you speak a language other than English at home? * must provide value
No
Spanish
Other
Please specify which language(s):
If yes, how well do you speak English? Very well
Well
Not well
Not at all
What is the setting of your current position at admission? (Examples: - Undergrad/Grad Students would select University or Community College - Practicum/Clinical Candidates would select University or Hospital you are being trained by - Practicing Professionals would select their employer's setting (Agency, Hospital, Public School, etc.)
* must provide value
University
Community College
Hospital
Agency
Public School
Non-Profit
N/A
Other
Please specify the name of your current school, agency, or company:
What is the best way to describe your current position title at admission?* must provide value
Graduate Student Undergraduate Student Fellow Self Advocate Family Advocate Community Advocate Medical Resident Teacher Research Assistant Other
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
Unrecorded
Are you an undergraduate, practicing professional, or neither? * must provide value
Undergraduate
Practicing professional
Neither
Primary e-mail address (non-KUMC)* must provide value
Address (Street Line 1)* must provide value
Address Line 2 (Apt/Suite #)
City* must provide value
State* must provide value
Zip Code* must provide value
Country* must provide value
County of origin (i.e. Johnson) * must provide value
Please describe the population density (how many people in an area) of your county of origin.
Use the population density map found here: http://www.ipsr.ku.edu/ksdata/ksah/population/popden2.pdf
* must provide value
Frontier
Rural
Densely-settled rural
Semi-urban
Urban
Best Telephone Number* must provide value
Is your Permanent Address the same as above? Yes
No
Permanent Address
Permanent City
Permanent State
Permanent Zip
Permanent County
Country of Origin
I understand that United States Citizenship or a permanent resident visa is a requirement for this traineeship Yes
No
Have you ever been convicted of a felony or a non-traffic related misdemeanor?* must provide value
Yes
No
If yes, please explain.
Academic Degree/Credential Achieved (i.e. BA, MS, PhD)* must provide value
Traineeship Discipline* must provide value
Psychology
Occupation Therapy
Speech Language Therapy
Social Work
Nursing
Audiology
Physical Therapy
Special Education
Dietitian
Dentistry
Medical
Public Administration
Family/Community Advocate
Self-Advocate
Other/Not Sure
Please list Other Discpline or let us know if you have questions about your discipline.
How many hours a week are you available to commit to LEND? 16 hours a week
8-15 hours a week
less than 8 hours a week
I am interested in a short-term experience
Not sure
High school diploma/GED? Yes
No
If no diploma, indicate highest grade completed Middle School
9th
10th
11th
12th
Name and location of current degree program
Course of Study
Dates attended, list from (M/YY) to (M/YY)
Total hours completed
List degrees/diplomas/certificates
Do you have additional colleges to list? Yes
No
Name and location of college/university program
Course of study
Dates attended, list from (M/YY) to (M/YY)
Total hours completed
List degrees/diplomas/certificates
Do you have additional colleges to list? Yes
No
Name and location of college/university
Course of study
Dates attended, list from (M/YY) to (M/YY)
Total Hours Completed
List degrees/programs/certificates
Do you have additional colleges to list? Yes
No
Please list additional educational institutions attended
Current/Most Recent Employer
Address, city, state, zip
Employed from (M/YY) to (M/YY)
Position
Supervisor's name
Phone number
Job Duties
Employer 2
Address, City, State for Employer 2
Dates employed for employer 2 (from M/YY to M/YY)
Position for employer 2
Supervisor for employer 2
Phone number for employer 2
Job duties for employer 2
Employer 3
Address, city, state for employer 3
Dates employed for employer 3 (from M/YY to M/YY)
Position for employer 3
Supervisor for employer 3
Phone number for employer 3
Job duties
Any other related experiences (not included in Resume')
Career Plans
Ideal position: What percentage of time would you desire in the following areas?
Special Skills and Interests
What experience do you have with people with disabilities, either personally or professionally?
I affirm that the facts set forth above in my application for the LEND Traineeship are true, correct and complete to the best of my knowledge. I understand that I may be required to submit information not requested on this application form; that the agency may verify any information provided by me in the selection process; and that incomplete information or omission of my signature, or other required materials, is just cause for rejection of my application.
Date Today M-D-Y
Upload letter of interest
Upload Resume or Curriculum Vitae
Upload Reference Letter 1
Upload Reference Letter 2
Upload Transcripts (scan or PDF)
Please submit completed application form.
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