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LEND Application

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Please complete the survey below.

Thank you!

Thank you for applying to the KUMC Leadership Education in Neurodevelopmental Disabilities Program.

We will make accomodations if you have a disability that requires assistance completing the application form or interviewing. Please notify us in advance so we can make the necessary arrangements.

Please contact Jessica Schuttler at jschuttler@kumc.edu or call 913-945-7942 for accommodations.

Date of Application (M/D/Y)

M-D-Y

Last Name

* must provide value

First Name

* must provide value

Middle Initial

List other names under which records may be obtained

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Were you referred to LEND from a TRIO program and are you a current undergraduate?

Yes

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Please note that TRIO program applicants only need to upload ONE letter of reference.

Please enter the name of your college/university

Gender (per Federal Reporting requirements):

* must provide value

Male

Female

Other

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Gender Identity

Date of Birth

* must provide value

Social Security Number (123-45-6789)

If you are an International student, please enter N/A

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

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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

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Do you speak a language other than English at home?

* must provide value

Spanish

Other

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Please specify which language(s):

If yes, how well do you speak English?

Very well

Well

Not well

Not at all

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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

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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

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

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Are you an undergraduate, practicing professional, or neither?

* must provide value

Undergraduate

Practicing professional

Neither

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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

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Best Telephone Number

* must provide value

Is your Permanent Address the same as above?

Yes

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Permanent Address

Permanent City

Permanent State

Permanent Zip

Permanent County

Country of Origin

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

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Please list Other Discpline or let us know if you have questions about your discipline.

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Have you ever been convicted of a felony or a non-traffic related misdemeanor?

Yes

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If yes, please explain.

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I understand that United States Citizenship or a permanent resident visa is a requirement for this traineeship

Yes

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How many hours a week are you available to commit to LEND?
Funded, long-term trainees must commit 16 hours a week.
We have other, unfunded trainee positions available for fewer than 16 hours a week.

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

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High school diploma/GED?

Yes

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If no diploma, indicate highest grade completed

Middle School

9th

10th

11th

12th

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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

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Do you have additional colleges to list?

Yes

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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

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Do you have additional colleges to list?

Yes

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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

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Do you have additional colleges to list?

Yes

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Please list additional educational institutions attended

Institution, location, course of study, hours completed, list of degrees

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Current/Most Recent Employer

Address, city, state, zip

Employed from (M/YY) to (M/YY)

Position

Supervisor's name

Phone number

Job Duties

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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

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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

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Any other related experiences (not included in Resume')

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Career Plans
Please let us know how you plan to use your LEND experience to further your commitment to serving children and families affected by disability.

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Ideal position: What percentage of time would you desire in the following areas?
a. Direct Service ____%
b. Teaching ____%
c. Research ____%
d. Administration ____%
e. Consultation ____%

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Special Skills and Interests
Please describe any other related abilities, qualifications or experiences not mentioned elsewhere (e.g. specialty certifications, personal experience, computer skills, etc)

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What experience do you have with people with disabilities, either personally or professionally?

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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.

I understand that any omission of information, or erroneous information provided in any part of the LEND application process, would be sufficient cause for termination from the program.

I further understand that if I have ever been convicted of a crime, I must disclose all crimes now by completing the application for employment sections pertinent to the subject.

Add signature

Date

M-D-Y

Upload letter of interest

Upload file

Upload Resume or Curriculum Vitae

Upload file

Upload Reference Letter 1
*If your reference prefers to send their letter to us directly, they can do so at kansaslend@kumc.edu.

Upload file

Upload Reference Letter 2
*If your reference prefers to send their letter to us directly, they can do so at kansaslend@kumc.edu.

**TRIO program applicants only need to upload one letter of reference.

Upload file

Upload Transcripts (scan or PDF)

Upload file

Please submit completed application form.

Questions please contact
Jessica Schuttler, Training Director
jschuttler@kumc.edu
Office (913) 945-7942

The University of Kansas Medical Center
Division of Developmental-Behavioral Sciences
Center for Child Health and Development
MS 4003, 3901 Rainbow Boulevard
Kansas City, Kansas 66160

KUMC is an affirmative action, equal opportunity institution and welcomes applications from all qualified persons regardless of sex, race, color, religion, sexual orientation, disability, national origin, veteran status, ancestry or age. For additional information about the EEO/AA policies and procedures, see the EEO/AA section of the KUMC Faculty Handbook.

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