Personal

Name:
Email:
UW ID Number (if applicable):

Home Phone:
Work Phone:
Mobile Phone:

Date of Birth:
Gender: Select... Male Female

Local Address Information

Street Address:
City:
State:
ZIP Code:

Home/Permanent Address Information

Street Address:
City:
State:
ZIP Code:

US Citizen: Select... Yes No

Visa Status:

Clinical Discipline: Select... Nursing Nutrition Social Work Respiratory Therapy Pharmacy Pediatric Pulmonology

Availabilty

I am available to begin a traineeship:

I will be available for training hours per month

Please Respond to the Following:

Describe any prior experience working with children with special health care needs and/or pulmonary conditions. Include any relevant course work, seminars or workshops. If none, please describe your interest in learning more about working with children with special health care needs and/or pulmonary conditions.

What does leadership mean to you? What personal qualities do you possess that illustrates your leadership potential?

Provide examples of prior leadership roles you have had, both paid and volunteer (eg: community organization board member, religious education teacher, community activity leadership, etc).

What do you hope to gain from participating in the PPC interdisciplinary leadership training program?

Resume/CV

After completing this online form, please email info [at] uwppc [dot] org a current resume/CV, including the requested information below:

College Education

1. Undergraduate College/ or University (Degree, Year)
2. Graduate College/ or University (Degree, Major, Year)
3. Current Academic Program (Degree, Major, Anticipated Date of Graduation)
4. Professional Licensure Currently Held

Related Work Experience

1. Briefly describe any prior clinical experience in maternal and child health, pediatrics, or public health.
2. Briefly describe any prior experience as a member of an interdisciplinary team.

Goals/Interests

1. Address your primary goals for the PPC traineeship.
2. Identify any special interests.
3. Address your professional goals upon completion of the traineeship.
4. One of the missions of the PPC traineeship is to prepare you to work with an increasingly diverse population. Briefly describe any unique qualifications which will help us accomplish this mission.

References (List Three)

• Include Name, Address, and Phone Information.