Which LEND training year are you applying for?
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2022/2023 Cohort (Sept 2022-May 2023)
How did you hear about the San Diego LEND program?
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1. Please indicate your preferred honorific (for example, Mx., Mr., Mrs., Ms., Dr., etc.)
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4. What pronouns do you use?
7. Preferred Phone Number
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8. Is this Home Phone, Work Phone, or Cell Phone?
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9. What is the best way to contact you?
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Phone
Email
10. Current Address Line 1
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11. Current Address Line 2
13. Current Address State
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14. Current Address Zip/Postal Code
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15. What is your connection to Imperial County? (Select all that apply)
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I used to live there
I currently live there
I used to work there
I currently work there
N/A
Today M-D-Y
17. Which of the following best describes you?
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Male
Female
Non-Binary
Prefer to Self-Identify
17a. If you prefer to self-identify, please write in response here.
18. United States Residency Status
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US Citizen
Permanent Resident
Non-US Resident
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.
20. What is your ethnicity?
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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
21. "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. Are you (check all that apply):
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Person with a disability
Person with a special healthcare need
Parent of a person with a disability
Parent of a person with a special healthcare need
Family member of a person with a disability
Family member of a person with a special healthcare need
None of the above
22. Please indicate the highest degree/credential you have completed:
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High school diploma
GED
BS/BA
MS/MA
MD
PhD
Other
23. Do you plan to be enrolled as a student or seeking an academic degree while enrolled in the San Diego LEND training program?
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Yes
No
(Note: For graduate students, postdoctoral fellows, medical residents and fellows, and trainees who have employment through their academic institution as part of training program, please select yes and complete this "student/trainee" section of the application.)
23a. If yes, indicate your level of enrollment:
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Part-time student
Full-time student
23b. What is the name of your current school/academic institution?
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23c. Academic level for current enrollment status (not highest degree earned):
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High School
Undergraduate
Masters
Doctoral
Postdoctoral
Residency
Fellowship
23d. Academic degree for program for which you are currently enrolled:
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MA/MS
MSW
MD
EdD
PhD
Other
23f. Do you currently have a faculty or family advisor affiliated with the LEND?
Yes
No
23g. If yes, who is your advisor?
24. Do you plan to be employed while enrolled in the San Diego LEND training program?
* must provide value
Yes
No
(Note: For graduate students, postdoctoral fellows, medical residents and fellows, and trainees who have employment through their academic institution as part of training program, please complete the "student/trainee" section of the application, please select no and do not complete this employment section about your academic position.)
24a. If yes, please indicate if you will be working...
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Full-time
Part-time
24b. If yes, what is your current place of employment?
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24c. What is your current position/title?
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25. San Diego LEND trainees can reflect a range of disciplines. Please review the list of disciplines and select all disciplines that apply to you.
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Applied Behavioral Analysis
Audiology
Dentistry (Pediatric or Adult)
Disability Studies
Genetics/Genetic Counseling
Health Administration
Medicine/Adult (includes disciplines such as neurology, adult psychiatry)
Medicine/Pediatrics (includes disciplines such as pediatrics, developmental behavioral pediatrics, and child psychiatry)
Nursing
Nutrition
Occupational Therapy
Physical Therapy
Psychology (includes clinical psychology)
Public Health Policy
School Psychology/School Counseling
Social Work
Speech-Language Pathology
Special Education / Education
Other
N/A - None of these disciplines apply
25a. Other discipline, if not included in Question 25:
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26. If more than one discipline is selected, which is your primary discipline?
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27. Are you a family member of an autistic or neurodiverse individual?
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Yes
No
28. Are you an autistic or neurodiverse individual?
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Yes
No
29. Have you been a LEND trainee at another program in the past?
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Yes
No
29a. If yes, please indicate what type of trainee:
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Short-term
Medium-term
Medium-term advanced
Long-term
29b. If yes, at what LEND site were you a trainee?
* must provide value
30. Which San Diego LEND trainee track are you interested in being considered for?
* must provide value
Long-term Trainee (300+ hours of training during the September-May training year; around 8 hours per week, two half days of LEND activities per week
Advanced Medium-term Trainee (150-299 hours of training during the September-May training year; around 4-8 hours of LEND activities per week)
Medium-term Trainee (40-149 hours of training during the September-May training year; around 1-4 hours of LEND activities per week)
31. I would like to be considered for the LEND program as a ...
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Graduate/Post-graduate trainee (Note: this option includes all academic training programs including residency and fellowships)
Practicing professional applicant
Family member of an autistic or neurodiverse individual
Autistic or neurodiverse self-advocate
31a. If you fit more than one trainee category (for example, a graduate student who is also the family member of a neurodiverse individual), please indicate the LEND categories that are applicable to you here:
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32. What aspect of the San Diego LEND program are you most interested in/excited for?
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Letter of Reference
Will reference letter/form be sent directly to San Diego LEND by your reference or will you upload the completed reference letter/form here?
Letter will be sent by reference
Letter will be uploaded by applicant
Please write in the name of your reference:
(using LEND reference form)
Additional required application materials for graduate/post-graduate applicants include:
1. Resume/CV
2. A one page statement of interest that addresses applicant’s interest in promoting equitable access to evidence-based care, applicant’s leadership strengths and goals in the field of ASD/DD, and skills and competencies applicant is interested in developing during San Diego LEND training.
Graduate/Post-graduate: Resume/CV
Graduate/Post-graduate: Statement of Interest
Additional required application materials for practicing professional applicants include:
1. Resume/CV
2. A one page statement of interest that addresses applicant’s interest in promoting equitable access to evidence-based care, applicant’s leadership strengths and goals in the field of ASD/DD, and skills and competencies applicant is interested in developing during San Diego LEND training.
Practicing Professional: Resume/CV
Practicing Professional: Statement of Interest
Additional required application materials for family member applicants include:
1. One page statement describing your experiences as a family member of a neurodiverse individual. Please include any leadership, community, or advocacy interest or experiences related to ASD/DD that you may have.
Family Member Applicants: Statement of Interest
Additional required application materials for self-advocate applicants include:
1. One page statement describing your experiences as a neurodiverse Self-Advocate. Please include any leadership, community, or advocacy experiences, which can include experiences advocating for yourself.
Self-Advocate Applicants: Statement of Interest
If you have any additional information pertaining to this application that you would like to share please do so here.
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