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LEAP Steering Committee Application

Applicant

Thank you for submitting a nomination for the APA Minority Fellowship Program's LEAP Steering Committee. Please complete the information below and upload the applicable documents. By completing this information, you are submitting your application for review. If approved, you will be added to the LEAP website (editorial edits are possible). If you have any questions, please contact us at mfp@apa.org.

First Name: *This question is required.

Last Name: *This question is required.

Degree: *This question is required.

Contact Information: *This question is required.

Address 1:
Address 2:
Address 3:
City:
State:
Zip:
Phone:
Email:

Institution: *This question is required.

Position: *This question is required.

Gender:

Please enter an 'other' value for this selection.

Ethnicity and Race Based on self-identification, select all boxes that apply to your ethnicity/race. Please provide additional information for each selected box (e.g. Cherokee, Haitian, Colombian).

Asian or Asian American (please specify) Please enter an 'other' value for this selection.
Black or African American(please specify) Please enter an 'other' value for this selection.
Hispanic or Latino(please specify) Please enter an 'other' value for this selection.
Native American / Alaska Native (please specify) Please enter an 'other' value for this selection.
Native Hawaiian or Other Pacific Islander
White or Caucasian (please specify) Please enter an 'other' value for this selection.
Other - Write In Please enter an 'other' value for this selection.

Have you been a fellow in any of the Minority Fellowship Programs (Psychology Summer Institute, Mental Health and Substance Abuse Services, Services for Transition Age Youth, Interdisciplinary Minority Fellowship Program)?

Please list your relevant research areas with a few brief keywords:

Letter of Interest: *This question is required.

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Curriculum Vitae: *This question is required.

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Please paste a short professional biographical paragraph here (if you become a member, this will be used on the LEAP website):

Please upload a professional photo (if you become a member, this will be used on the LEAP website):

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