Fellowship Application Form

Use the following form to begin your application for the Leadership Education in Adolescent Health Fellowship program (UW LEAH).  You may print a PDF version to assist you in compiling necessary information before submission.

In addition to the form below, you must also e-mail

TWO Letters of Recommendation to:

LEAH Coordinator
Division of Adolescent Medicine
Email: UWLEAH@seattlechildrens.org 


Contact Information
First M. Last, Degrees
Your full mailing address.
Undergraduate Education
Graduate/Professional Education (include current training program, if applicable)
Internship, Residency, or Other Clinical Training Experience
Fellowships, Pre/Post Doctoral Training
APA format
Name, title, and address for 2 professional reference who will be submitting a letter of recommendation.
Reference 1
Reference 2
Please upload the following files:
Files must be less than 2 MB.
Allowed file types: txt rtf pdf doc docx.
Files must be less than 2 MB.
Allowed file types: txt rtf pdf doc docx.
Non-Discrimination & Disability Access Policy

University of Washington LEAH program reaffirms its policy of equal opportunity regardless of race, color, creed, religion, national origin, sex, sexual orientation, age, marital status, disability, or status as a disabled veteran or Vietnam era veteran in accordance with University policy and applicable federal and state statutes and regulations. The University of Washington LEAH program is committed to providing access, equal opportunity and reasonable accommodation in its services, programs, activities, education and employment for individuals with disabilities.

Optional Diversity Information

Consistent with our goal of enhancing the intellectual and social enrichment of the University community, the University of Washington LEAH program actively seeks and welcomes applicants from diverse backgrounds. We are asked to maintain gender, ethnicity and disadvantage information for federal grants and other statistical purposes. Therefore, we would appreciate information about:

Please select one. NIH defines disability as any physical or mental impairment that substantially limits one or more major life activities.
An individual from a disadvantaged background is defined as one who comes from a family with an annual income below a level based on low-income thresholds according to family size published by the U.S. Census Bureau, adjusted annually for the changes in the Consumer Price Index, and adjusted by the Secretary of the U.S. Department of Health and Human Services (Secretary) for use in all health professions programs. The Secretary periodically publishes these income levels in the Federal Register.