Council Applicant Questionnaire Step 1 of 2 50% Print Name:* First Last Best e-mail address* County of Residence*AlachuaBakerBayBradfordBrevardBrowardCalhounCharlotteCitrusClayCollierColumbiaDeSotoDixieDuvalEscambiaFlaglerFranklinGadsdenGilchristGladesGulfHamiltonHardeeHendryHernandoHighlandsHillsboroughHolmesIndian RiverJacksonJeffersonLafayetteLakeLeeLeonLevyLibertyMadisonManateeMarionMartinMiami-DadeMonroeNassauOkaloosaOkeechobeeOrangeOsceolaPalm BeachPascoPinellasPolkPutnamSanta RosaSarasotaSeminoleSt. JohnsSt. LucieSumterSuwanneeTaylorUnionVolusiaWakullaWaltonWashingtonEthnicity* White Black or African American American Indian and Alaska Native Hispanic/Latino Asian Native Hawaiian or Other Pacific Islander Two or more races Unknown Gender* Male Female Prefer not to answer Please select your age range:* 18-24 25-34 35-44 45-54 55-64 65 and over 1. The following categories are defined under the Federal Developmental Disabilities (DD) Act of 2000.* Individual with Developmental disability Parent or guardian of a child with a developmental disability Immediate relative or guardian of an adult with mentally impairing conditions who cannot advocate for themselves Individual, parent/guardian of a child, immediate relative/guardian of an adult who currently resides or previously resided in an institution Representative of a local, non-governmental agency that provides services to individuals with DD Individual who represents a private, non-profit group concerned with services with individuals with DD If you are an individual with a developmental disability. What is your disability? (check all that apply)* Intellectual Disability (Section 393.063(24), Florida Statutes) Autism (Section 393.063(5), Florida Statutes) Spina Bifida (Section 393.063(40), Florida Statutes) Cerebral Palsy (Section 393.63(6), Florida Statutes) Prader-Willi syndrome (Section 393.063(29), Florida Statutes) Down syndrome (Section 393.063(15), Florida Statutes) Phelan-McDermid syndrome (Section 393.063(28), Florida Statutes) Other N/A If other, please specify your disability*Provide a brief narrative on how you meet the category marked in question #1.2. Do you know anyone who has served as a DD Council Member?*Please select below: Yes No If Yes, please list individual's name and relationship to you:*3. Have you served or currently serve on any Boards or Councils?* Yes No If Yes, what office or position(s) have you held?*4. Will you, any of your relatives, or other individuals with whom you are associated potentially benefit from activities or decisions of the Council?*Please select below: Yes No If Yes, please explain below:*5. Are you a Partners in Policymaking graduate? and if so what year did you graduate?*Please select below: Yes No PIP Graduation Date:* MM slash DD slash YYYY What was your personal PIP project?*6. Are you involved in any volunteer groups in your local community?* Yes No If Yes, please list below:* 7. We are a Statewide Council and conduct business both electronically via-email and webinars, as well as face to face.A. Do you have access to the following: Phone, Computer, Tablet (e.g. Apple iPad), E-mail, Zoom, Microsoft Teams or similar conferencing platform, Transportation* Yes No B. Do you require any accommodations to effectively participate in Council Meetings: Navigation Assistance with Zoom or similar conferencing platform, Transportation, Personal Care Attendant, Direct Support/Assistance to Participate in Meeting.* Yes No If yes, please explain:*8. Provide the best way to reach you:Phone number*Address* Street Address City State / Province / Region ZIP / Postal Code Please provide an updated resume:*Accepted file types: pdf, doc, docx, Max. file size: 128 MB. Maximum allowed on this form: 25MBSignature:*
