Application This is the application form for potential LEND Trainees Name(Required) First Last Phone(Required)Email(Required) Alternate Email(Optional) Address(Optional) City State / Province / Region ZIP / Postal Code Highest Degree Attained(Optional)Not ApplicableHigh SchoolBachelorsMastersDoctorateDiscipline(Required)Applied Behavior AnalysisFamily LeadersHealth AdministrationNursingNutritionOccupational TherapyPediatric MedicinePhysical TherapyPsychologyPublic HealthSocial WorkSpecial EducationSpeech-Language PathologySelf-AdvocacyOther (fill in blank below)Other Discipline:(Optional unless you selected "Other" above) Please describe your discipline. Personal Relationship with DisabilitySelect all that apply. Family member of a person with a disability Family member of a person with a special health care need Parent of a person with a disability Parent of a person with a special health care need Person with a disability Person with a special health care need Provide the names and email addresses for two references who have experience with your advocacy, academic, professional, and/or volunteer work. They will receive an email from LEND with a link to a short form to complete. A letter of reference is not required. For applicants in graduate school, contact information for professors is preferred. References should not be members of your family.1st Reference Information Dr.MissMr.Mrs.Ms.Prof.Rev. Honorific (Dr. Mr. Ms. Etc) First Name Last Name Email - 1st ReferencePlease provide an email address for your second reference 2nd Reference Information Dr.MissMr.Mrs.Ms.Prof.Rev. Honorific (Dr. Mr. Ms. Etc) First Name Last Email - 2nd ReferencePlease provide an email address for your second reference. Please attach the following documents to complete the NM LEND application: 500-word essay describing your interest in joining the NM LEND program. Include your experience with disability and your plans for leadership in the field. Resume. University transcripts (graduate students ONLY). UploadPlease consider putting your name in the document name before you upload. (Maximum of 6 documents) Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 128 MB, Max. files: 6. CommentsIs there anything else you'd like to tell us? (Optional)StatusCurrentPendingDeferredCompletedWithdrawnNot AcceptedInterview Date Month Day Year Date Sent Recommendation Links Month Day Year Offered? Yes No Other Accepted? Yes No Other Fiscal Year Staff NotesCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
