Partners in Policymaking

Application for Participation

Name:           __________________________________________________

 

Address:        _________________________________________________

 

___________________________________      Zip Code: _________

         

Telephone:     __________________________________________________

 

E-Mail:         _________________________________________________

         

Sex:     _______ Male              ______ Female                      

 

Race:    ____________________

 

1.                   Are you a person with a developmental disability?

    

   _______ Yes         _______ No

    

   Your age: _________

    

   What is your disability or disabilities?

   ______________________________________________

             ____________________________________________________

             ____________________________________________________

    

2.                   Are you a parent or guardian of a child with a developmental disability? If you have more than one child with a disability, please answer for each child.

    

   _______ Yes  _______ No

    

   Child’s age: ___________

    

    

   What is your child’s disability or disabilities?

   ____________________________________________

    

    

   Describe how the disability affects your child’s ability to function in at least three areas of major life activities:

   ____________________________________

    

   ____________________________________

    

   ____________________________________

    

   Does your child live at home?         _______ Yes                  _______ No

    

   Describe your child’s school placement if applicable:

   ___________________________________________________________________

    

   Do you have other children?        ________ Yes                    _______ No

    

   If yes, what are their ages?    __________________________________________

3.                   What services (employment, attendant, respite care, case management, etc.) are you or your child currently receiving?

   ________________________________________

    

   ________________________________________

    

4.                   Why are you interested in participating in the Partners in Policymaking program?

   ___________________________________________

    

   ____________________________________________

    

   ___________________________________________

    

5. Is there a specific area of concern or issue that encourages you

   to apply to this program?

   _________________________________________

    

   _________________________________________

    

6.                   Participants are expected to attend each 2 or 3-day session, held monthly in the Central Florida area. Will you make a commitment to attend each session?

    

   _________ Yes      _________ No

    

   1. Will you travel to the Central Florida area to attend the scheduled meetings?

       

      _________ Yes           _________ No

       

   2. Would you prefer 2-day or 3-day sessions?

       

      ________ 2-day sessions        _________ 3-day sessions

       

7.                   Are you willing to complete homework assignments?

    

   _________ Yes           _________ No

    

8.                   Are you willing to continue your advocacy after completion of the program and continue to report your achievements to the program?

    

   _________ Yes           _________ No

    

9.                   Please list any special accommodations necessary for you to participate in this program. Including accessibility requirements, interpreters, respite care, etc.

   ________________________________________________________________

    

   ________________________________________________________________

    

   _________________________________________________________________

    

10.               Please list any membership in advocacy organizations and any offices held. (Membership in an organization is not a requirement).

    ___________________________________________________________________

     

11.               What type of experience do you have in advocating for people with developmental disabilities?

    ___________________________________________________________________

     

    ___________________________________________________________________

     

    ___________________________________________________________________

     

12.               Please tell us a little about yourself and your family:

    _________________________________________________________________

    _________________________________________________________________

    _________________________________________________________________

    _________________________________________________________________

     

13.               Please list two references (include name, address, and phone number):

     

    1)      ______________________________________________________

    ______________________________________________________

    ______________________________________________________

    ______________________________________________________

     

    2)      ______________________________________________________

    ______________________________________________________

    ______________________________________________________

    ______________________________________________________

     

14.               How did you learn about Partners in Policymaking?

    ___________________________________________

    ___________________________________________

      

15.               What do you hope to accomplish as a result of this program?

    _____________________________________________

    _____________________________________________

    _________________________________________

 

Please return completed application to:

Partners in Policymaking Coordinator

Debbie Hannifan

Post Office Box 2864

Lakeland, Florida 33806

Phone (863) 738-6367    Fax: (863) 688-2551

or e-mail to Dhannifan@tampabay.rr.com

 

Should you need an alternative form of this applicationor other assistance, please contact us.