Fellow Application

Date*

Full Name*

Gender Pronouns*

Which of the following groups do you identify with?* (Check as many as apply)
Black/African AmericanHispanic/LatinxAsianNative AmericanLGBTQ+Other

Street Address*

City*

State*

Zip*

Email*

If you are affiliated with an OG training program, please list.*

Please list the dates and times of your summer training.*

How will the training be offered?* (Select one)
Fully In-PersonFully RemoteHybrid (In-Person and Remote)

How do you plan to offer the coursework?* (Select one)
The coursework will begin prior to the practicum and continue throughout the practicum.All of the coursework will be completed prior to the practicum.

What is the model for the practicum?* (Select one)
Observations will be completed in-person.Observations will be completed remotely or via video.Observations will be completed in a hybrid model (some in-person, some remote.)

How do you plan to offer mentoring throughout the practicum to the trainee?*

Does your coursework and practicum registration include the cost of materials? If not, please describe the items and cost of materials trainees will be asked to purchase separately.*

Describe how you have committed yourself to understanding and aiding in the pursuit of equity and inclusion in your professional and/or personal life?*