LEND Application

Title

Degree

Full Name

First

Middle

Last

Suffix

Contact Info

Email Address

Personal Email Address

Phone Number

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

What is the best way to contact you? What is the best way to contact you?

How did you hear about this program?

Disabilities

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

Please pick the best answer(s) below describing your relationship with disabilities (click all that apply)

Demographic Information

US Citizen

Yes

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

Yes

Languages

Please list all languages you are fluent in.

Date of Birth

Accommodations

What, if any, accommodations do you need to help you actively participate in educational opportunities offered online or in-person? (For example: large print, Braille, sign language interpreter)

Education/Current Degree Program

What is the Highest Degree program you have completed?

What is the institution you have received your Highest Degree from?

Are you currently enrolled in an academic program?

Yes

If Yes, please state the institution and program you are enrolled in.

Please list credentials or licenses you currently maintain.

Choose the LEND track to which you wish to apply

Which LEND trainee track are you applying for?

Is there a specific age group or type of disability in which you are particularly interested in learning about?

Select a Discipline

For the next question, please select a discipline where you have a degree or are pursuing a degree in that discipline only. To select Family you must have a family member with a disability. To select self-advocate you must be a person with a disability. If you have the ability to apply to more than one discipline, select the discipline where you feel like you can contribute the most to the program.

Why are you interested in participating in the Stony Brook LEND Interdisciplinary Traineeship?

ASD/DD Professional and/or Personal Experiences

Please describe your professional and/or personal experiences with individuals with ASD/DD.

Career Goals

Please describe your career goals, and how the SBU LEND training will assist you in achieving these goals.

Commitment to Improving Health & Well-Being of the ASD/DD Population

Please discuss how your area of study/work and/or lived experience addresses or supports a commitment to improving the health and well-being of the ASD/DD population.

Leadership

Please describe your leadership potential and experience.

Reference Information

Reference Name

Reference Email Address

Reference Agency or Institution

Reference Job Title (of the Reference)

Recommendation Letter

Please upload recommendation letter from your reference.
One file only.
20 MB limit.
Allowed types: txt rtf pdf doc docx odt ppt pptx odp xls xlsx ods.

Resume/CV

One file only.
20 MB limit.
Allowed types: txt rtf pdf doc docx odt ppt pptx odp xls xlsx ods.