Fillable Advocate Trainee Application 2022 2023

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Advocate Trainee Application 2022 2023

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1
Advocate
Trainee Application
2
A collaboration between
The University of Texas Health Science Center at Houston
University of Houston
Texas Woman’s University
University of Houston - Clear Lake
Baylor College of Medicine
TO: Interested Individuals / Self-Advocates with Diagnosed Autism Spectrum Disorder or other
Neurodevelopmental Disabilities
FROM: Prisca Tihfon, Program Coordinator
SUBJECT: LoneStar LEND Fellowship Program
Applications are now being accepted for the LoneStar LEND Fellowship Program at the
University of Texas Health Science Center at Houston. Enclosed please find program
information and an application form. Adults with developmental disabilities, parents and/or
siblings of individuals with developmental disabilities, and individuals from diverse
backgrounds are encouraged to apply.
Application Checklist
□
Completed Advocate Trainee application
□
Résumé / CV
□
Two letters of recommendation including LEND cover sheet
□
(if applicable) Signed Employer Letter found on page 12
Please return application materials by April 30, 2022 to:
Annie Rangel:
Email (preferred): Annie.A.Rangel@uth.tmc.edu -OR-
Mail: Annie Rangel | LoneStar LEND | 6410 Fannin St. Suite 732 | Houston, TX 77030
You will receive a confirmation email when your application is received. If you do not
receive a confirmation email within 3 business days of submitting your application,
please call 713.500.3637.
Supported in full by Project #T73MC22236 from the Maternal and Child Health Bureau (Public
Health Service Act, Section 399BB (e)(1)(A), as amended by the Combating Autism Reauthorization
Act (CARA) of 2011), Health Resources and Services Administration, Department of Health and Human
Services.
3
A collaboration between
The University of Texas Health Science Center at
Houston
University of Houston
Texas Woman’s University
University of Houston - Clear Lake
Baylor College of Medicine
LoneStar LEND Program Requirements (abridged)
1. LEND Orientation:
a. First Friday in September
2. LEND Seminars
a. September – June: Fridays 9:00am – 4:45pm
3. Service Learning Project
a. Weekday time with team members
4. Families as Teachers
a. Four lectures from Family Faculty; two encounters with assigned mentor family
and attendance at two parent panels + one self-advocate panel
5. Clinical Practica
a. 23 clinical rotations (1/2 day – full day each)
b. Completed outside of Friday LEND seminars
6. Leadership Weekend
a. Friday/Saturday, in September (8:00am - 5:00pm)
7. LEND Conference
a. Early Fall (Thursday – Friday); Houston, TX
8. Other Conference Requirement
a. BCM Transition Conference: Thursday – Friday in October; Houston, TX
OR
b. Texas Transition Conference: Thursday - Friday in February; Location TBA
9. Developmental Screening events
a. Two Saturdays during LEND Year
4
LoneStar LEND Program Requirements
The mission of the LoneStar LEND Program is to create leaders in the field of Autism
Spectrum Disorder and other Neurodevelopmental Disabilities (ASD/DD), utilizing an
interdisciplinary training model focused on cultural competence and evidence-based
practice. During their 10 month appointment, each LEND Trainee will complete a
total of 400-500 hours of training and learning activities including:
• LEND Didactic Seminars
• Leadership and Cultural Competence Training
• Clinical Practicum
• Conference Participation
• Families as Teachers Program
• Service Learning Project
• Additional LEND activities including leadership readings & reflections, outreach, etc.
LEND Didactic Seminars and Leadership/Cultural Competence Training
Mandatory sessions will be held on Fridays throughout your LEND appointment. For a sample of
the previous year’s didactic seminar calendar, visit www.LoneStarLEND.org.
These sessions will occur mainly at the UTHealth University Center Tower, 7000 Fannin; however
some may be scheduled at the McGovern Medical School, 6431 Fannin or the UTHealth School of
Nursing (SON), 6901 Bertner. Four ninety-minute sessions are scheduled each day. Training
sessions will include:
• LEND Orientation August (exact date TBD)
• Didactic Seminars
• Leadership and Cultural Competency Curriculum (held on a Friday/Saturday)
• Families as Teachers, Research and Clinical Review Sessions
• Team Building and Group Projects
• Leadership Readings and Book Club Discussions
Attendance at the seminars is required. A limited number of absences are allowed for professional
conflicts or illness. Please review the attached attendance policy.
Clinical Practicum
Trainees will participate in a wide variety of clinic and community observational experiences. A
total of 23 clinical rotations must be completed within the LEND year; each rotation spans between
4 - 8 hours. Trainees are responsible for contacting clinics to schedule observations and will keep
a log of observational experiences for review by the Training Coordinator at periodic clinical review
sessions.
5
Conference Participation
All Trainees will attend the annual LoneStar LEND conference held in the early Fall (exact date
TBD). Trainees are also required to attend either the Texas Transition Conference, or the Baylor
Chronic Illness Conference. Additionally, funds will be provided for Trainees to attend at least one
additional conference (from a group of selected conferences) or professional development
opportunity during the program year.
Families as Teachers Program
Each Trainee will be paired with a mentor family of a child with an ASD/ND to provide an
opportunity for Trainees to experience a family’s viewpoint into the process of diagnosis,
treatment, and day-to-day life with ASD/ND. Trainees will schedule a minimum of two encounters
with their assigned mentor family prior to April 30th. In addition, Trainees will attend two parent
panels where a variety of disabilities and ethnic backgrounds will be represented. These
interactive panels will be moderated by the LEND Family Faculty members and will expose
Trainees to a variety of ASD/ND topics from the families' perspectives. Upon completion of the
Families as Teachers Program, Trainees will participate in a wrap-up session where each Trainee
reflects upon the experience through a brief presentation to faculty and their peers. The
presentation will focus on how system and service availability and/or gaps were highlighted by
the families’ experiences and ideas for services to fill those gaps. The Trainee will also highlight
how they were most impacted by the family practicum experience and how they anticipate this
will affect their practice in the future.
Service Learning Project
During the course of the LEND year, each Trainee pursues an area of particular personal interest
through the Service Learning Project. Conceptualized and completed in interdisciplinary groups of
3 - 4 Trainees, the Service Learning Project will provide multiple opportunities for trainees to
experience issues they will face in practice such as accountability, outcome-based approaches,
family-centered models, collaboration, and interdisciplinary decision-making. Each of these
components offers opportunities for trainees to enhance and strengthen their leadership skills.
Trainee groups will present their leadership project at the conclusion of their program (date TBD).
The Service Learning Project should focus on an issue in the field of disability/special health care
needs and systems change. Each project will result in production of a product (brochure, web
page, article, instructional video, etc.).
The Service Learning Project is an opportunity to integrate relevant material from LEND seminars
and take away a broader perspective of working with an interdisciplinary team.
In addition to the scheduled seminar sessions, Trainees can expect to spend an average of 8-12
hours per week on LEND activities such as clinical practicum, family practicum and other LEND
activities, assignments, and projects.
6
LEND Fellow Application
Advocate Trainee
Date Submitted:
Contact Information
Name:
Local Address: Permanent Address (if different from Local):
Home Phone: Day Phone:
Cell Phone:
Email:
What is the best way to contact you?
Home Phone Day Phone Cell Phone Email
Demographic Information
Gender: Male Female US Citizen? Yes No
Texas Resident? Yes No
Ethnicity: Hispanic/Latino Not Hispanic/Latino
Race: Black or African American American Indian/Alaska Native Asian
White
Language(s) Spoken:
Native Hawaiian/Pacific Islander
Level of Fluency (written and spoken):
Conversational Intermediate Native/Bilingual
Current Education (if applicable)
Current Degree Program:
College/University: GPA:
Program(s) of Study:
Advisor: Anticipated Date of Graduation:
Anticipated Degree: M.A. M.S. M.Ed. M.S.W. Ph.D. Other:
7
Prior Education
Undergraduate Education:
College/University: GPA:
Program/s of Study: Date of Graduation:
Degree Earned: B.A. B.S.
Other:
Graduate Education:
College/University: GPA:
Program/s of Study: Date of Graduation:
Degree Earned: M.A. M.S. M.Ed. M.S.W. Other:
Employment
Current Employer:
Job Title:
Start Date:
Hours/Week:
Position Responsibilities:
_
_
_
_
Advocate Status
Primary Diagnosis:
Age When Diagnosed:
Secondary Diagnosis (if applicable):
Age When Diagnosed:
8
Advocate Trainee Application Questions
Directions: Please answer each question below. Your answers can be as long or as short as
you choose. Answers should be typed and attached to the application packet for final
submission.
1. A large part of the LoneStar LEND initiative are the didactic seminars that take place
throughout the day on Friday’s from 9:00am – 4:45pm. There are typically four per
day, each lasting 90 minutes. Would you be able to attend these seminars, based on
your schedule?
2. Tell us a bit about yourself. This can include country of origin, hobbies, family life,
achievements, etc.
3. Please explain why you have an interest in applying for the LoneStar LEND Program.
How do you feel this program will be of benefit to you? What are your expectations?
4. As a LEND trainee what strengths would you bring to the program? What do you
anticipate as potential challenges?
5. What aspect of the LoneStar LEND program is of most interest to you? Why?
6. What history do you have acting as an advocate for yourself?
7. What is one of the most formidable challenges you have faced in your adult life with
your diagnosis? How have you handled it?
8. The LoneStar LEND program is designed to support the development of leadership
skills that will assist participants to be effectively engaged in positive social change
for people with disabilities. What do you believe are the characteristics of an
effective leader? Tell us about any opportunities you have had to be a leader. What
skills did you use? And what have you experienced as barriers to effective
leadership?
9. How would you hope to use the things learned as a LEND trainee in your life moving
forward?
10. How did you hear about the LoneStar LEND program?
9
A collaboration between
The University of Texas Health Science Center at Houston
University of Houston
Texas Woman’s University
University of Houston - Clear Lake
Baylor College of Medicine
LEND Fellow Recommendation Letter Cover Sheet
This form is to be completed by applicant and reference. Please attach a copy to each letter of
recommendation.
Email: Annie.A,Rangel@uth.tmc.edu | Fax: (713) 500-3630
|
To be Completed by Applicant:
Name Date of Birth (mm/dd/yy)
Applicant’s Statement I waive I do not waive my right to review reference materials
Applicant Signature Date
To be Completed by Reference:
How long have you known the applicant?
What is (or has been) the nature of your relationship? (i.e. instructor, supervisor, etc.)
How well do you know the applicant?
Extremely Well Fairly Well Not Very Well
Have you seen him/her directly care for children? Yes No
Have you seen him/her directly care for children with special needs? Yes No
Would you hire this applicant to work with children who have special needs? Why or why not?
On a separate page, please describe your estimate of the applicant’s potential for success as a LEND
fellow. Please include your appraisal of the applicant’s academic background, professional and/or
research experience, and leadership capacity.
Name and Title
Profession or Occupation
Reference Signature Date
Supported in full by Project #T73MC22236 from the Maternal and Child Health Bureau (Public Health Service Act,
Section 399BB (e)(1)(A), as amended by the Combating Autism Reauthorization Act (CARA) of 2011), Health
Resources and Services Administration, Department of Health and Human Services.
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10
A collaboration between
The University of Texas Health Science Center at Houston
University of Houston
Texas Woman’s University
University of Houston - Clear Lake
Baylor College of Medicine
LEND Fellow Recommendation Letter Cover Sheet
This form is to be completed by applicant and reference. Please attach a copy to each letter of
recommendation.
E
mail: Annie.A.Rangel@uth.tmc.edu | Fax: (713) 500-3630 |
To be Completed by Applicant:
Name Date of Birth (mm/dd/yy)
Applicant’s Statement I waive I do not waive my right to review reference materials
Applicant Signature Date
To be Completed by Reference:
How long have you known the applicant?
What is (or has been) the nature of your relationship? (i.e. instructor, supervisor, etc.)
How well do you know the applicant?
Extremely Well Fairly Well Not Very Well
Have you seen him/her directly care for children? Yes No
Have you seen him/her directly care for children with special needs? Yes No
Would you hire this applicant to work with children who have special needs? Why or why not?
On a separate page, please describe your estimate of the applicant’s potential for success as a LEND
fellow. Please include your appraisal of the applicant’s academic background, professional and/or
research experience, and leadership capacity.
Name and Title
Profession or Occupation
Reference Signature Date
Supported in full by Project #T73MC22236 from the Maternal and Child Health Bureau (Public Health Service Act,
Section 399BB (e)(1)(A), as amended by the Combating Autism Reauthorization Act (CARA) of 2011), Health
Resources and Services Administration, Department of Health and Human Services.
11
References
Please list three references (who are NOT your recommendation letter writers) that are
familiar with your character, work and/or scholarly experience.
Name:
Position:
Institution/Company:
Work Phone: Cell Phone: Home Phone:
Email:
Dates of Contact: _ to
Name:
Position:
Institution/Company:
Work Phone: Cell Phone: Home Phone:
Email:
Dates of Contact: _ to
Name:
Position:
Institution/Company:
Work Phone: Cell Phone: Home Phone:
Email:
Dates of Contact: _ to
I grant permission for LEND faculty and staff to contact the above references for additional comments and queries.
Signature Date
To be considered for LoneStar LEND Fellowship candidacy, you must submit this application, a copy of your Curriculum Vitae/
Resume, two recommendation letters, and a signed Employer Letter from your current employer. Incomplete application
packets will not be reviewed.
Completed application materials should be sent to: Mail: Annie Rangel | LoneStar LEND Program | 6410 Fannin St., Suite
732 | Houston, TX 77030
-OR-
Email (preferred): Annie.A.Rangel@uth.tmc.edu
You will receive a confirmation email when your application has been received.
If you do
not receive a confirmation email within 3 business days of submitting your application, please call 713.500.3637.
An interdisciplinary collaboration among:
University of Texas Health Science Center at Houston (UTHealth),
University of Houston,
Texas Woman’s University,
University of Houston Clear Lake, and
Baylor College of Medicine
Dear Employer,
has submitted an application to the LoneStar Leadership Education
in Autism and other Neurodevelopmental Disorders [L.E.N.D.] Training Program for the academic year
September 2022 through June 2023.
There are currently 52 LEND programs located in 44 US states, with an additional six states and three territories reached
through program partnerships. Collectively, they form a national network that works together to address national issues
of importance to children with special health care needs and their families. While each LEND program is unique, with its
own focus and expertise, they all provide interdisciplinary training, have faculty and trainees in the 16 Maternal-Child
Health disciplines, and include family members and individuals with disabilities as paid program participants.
Before we can finalize this application, we need assurance that this trainee will have the appropriate time to successfully
perform the components of the LEND training, which include the following:
Weekly didactic seminars scheduled on Fridays from 9am to 5pm;
23 Clinical observations scheduled in half-day time slots by the trainee during variable weekday business hours;
Service Learning Project for which the applicant must meet with his/her fellow trainees to complete, either during
regular business hours or after hours, depending on the trainee group and the specific Project;
Attendance at either the Baylor College of Medicine Chronic Illness and Disability Conference in October 2022
(exact date TBA) or the Texas Transition Conference in February 2023 (exact date TBA);
Attendance at one additional national or local conference occurring during typical business hours over several
days.
Your signature below attests to your agreement with
the time requirements for successful completion of the
LoneStar LEND. If you do not agree, kindly inform us by email to Annie.A.Rangel@uth.tmc.edu in addition to
informing the applicant.
Thank you for your time and consideration.
Signature
Date
Printed name
Position
Employer/ Company Name & Address
Phone
The University of Texas Health Science Center at Houston, LoneStar LEND Program, 6410 Fannin St, Suite 732 | Houston, Texas 77030
713.500.3637 voice | 713.500.3630 fax | www.LoneStarLEND.org
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Completed 11 April 2022

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