Council Applicant Questionnaire Step 1 of 2 50% Print Name:* First Last Ethnicity:* Asian Black Hispanic Native American White (Non-Hispanic) Other County of Residence*AlachuaBakerBayBradfordBrevardBrowardCalhounCharlotteCitrusClayCollierColumbiaDeSotoDixieDuvalEscambiaFlaglerFranklinGadsdenGilchristGladesGulfHamiltonHardeeHendryHernandoHighlandsHillsboroughHolmesIndian RiverJacksonJeffersonLafayetteLakeLeeLeonLevyLibertyMadisonManateeMarionMartinMiami-DadeMonroeNassauOkaloosaOkeechobeeOrangeOsceolaPalm BeachPascoPinellasPolkPutnamSanta RosaSarasotaSeminoleSt. JohnsSt. LucieSumterSuwanneeTaylorUnionVolusiaWakullaWaltonWashingtonBest e-mail address* 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 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. Mark everything you currently have access to:* Select All Phone Computer Tablet (e.g. Apple iPad) E-mail Zoom, Microsoft Teams or similar conferencing platform Transportation Personal Care Attendant Direct support/Assistance through family, or Support Coordinator Other: please explain below: If Other, please explain below:B. Mark any accommodations you may require to effectively participate in Council Meetings: Select All Navigation Assistance with Zoom and or Webinars Transportation Personal Care Attendant Direct Support/ Assistance to Participate in Meeting Other: please explain below If Other, please explain below:8. Provide the best way to reach you:Best phone number*Mailing 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:*
