Traineeship in Developmental Disabilities Application Form

Applicant Information

Full Name:
Last / First / M.I.
Address:
Street Address / Apartment/Unit #
City / State / ZIP Code
Home Phone: / ( ) - / Cell Phone: / ( ) -
Email Address: / Social Security Number: / - -

Voluntary Information

This information is being requested in accordance with federal regulations. The information is voluntary and will not be used when considering you for employment with our organization.
Racial or Ethnic Group
American Indian/Alaskan / Asian/Pacific Islander / Black/African American
Hispanic/Latino / White/Caucasian / Other
Gender
Female / Male

Citizenship

U.S. Citizen / Other (specify)

Are you or can you be certified as “handicapped” under federal law or by the New Jersey Department of Vocational Rehabilitation? (optional)

Yes No

How did you hear about this position?
Current/Former Trainee / Boggs Center Employee / Announcement from Academic Dept.
Job Fair / Placement Office / Web Site
Other

Academic Information

Names of colleges and universities attended (list current attendance first):

Name City State Program Dates of Attendance

-
(mm/yy)-(mm/yy)
-
(mm/yy)-(mm/yy)
-
(mm/yy)-(mm/yy)
Major/Discipline:
Degree Sought: / Date Anticipated:

Knowledge/Experience with Developmental Disabilities

List any coursework you have taken which relates to the field of developmental disabilities.

List and briefly describe any field placements, practica or observations you have completed on in which you are currently involved which relate to the field of developmental disabilities

Describe any other experience you have had which relates to the field of developmental disabilities

Please indicate the year-long time commitment you are willing and able to make with regard to the traineeship.

40-300 hours over the course of a full academic year

300 hours or more over the course of a full academic year

Do you know someone with a disability?

Yes (please explain):

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

Yes (please specify):

Why are you interested in pursuing a traineeship in developmental disabilities with the University Center for Excellence?

Letter of Recommendation

Please submit a letter of recommendation from your faculty advisor or another faculty member who is familiar with your work. Use the recommendation form provided. Give the attached description of the UCE Traineeship Program to the faculty member when you request a letter of recommendation.

First Last

Name of Recommender:

Title Organization
Address:
Street Address
City / State / ZIP Code
Phone Number: / ( ) -