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PIP Application

Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email Address*
The following questions are designed to ensure diversity in the selection of participants for the FDDC’s Partners in Policymaking™ Advocacy and Leadership Program and are required by the Council's federal funding agency, the Administration on Intellectual and Developmental Disabilities. Your information will not be reported individually; rather, total numbers are submitted for each of these factors.
Gender*
- Male
- Female
- Prefer not to answer
Ethnicity*
- White
- Black or African American
- American Indian and Alaska Native
- Hispanic/Latino
- Asian
- Native Hawaiian or Other Pacific Islander
- Two or more races
- Unknown
Area type*
- Urban
- Rural
Are you a person with a developmental disability?*
- Yes
- No
If Yes, please provide age:
What is your disability or disabilities?
Are you a family member who has decision-making responsibility for their family member with intellectual and developmental disabilities (e.g., parent, sibling, grandparent), or legal guardian of a person with intellectual and developmental disabilities? Please describe your role and if you have more than one child with a developmental disability, please answer for each child.
Child’s Age
What is your child’s disability or disabilities?
Describe how the disability affects your child’s ability to function in 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?
What services (supported employment, attendant, respite care, case management, etc.) are you or your child currently receiving?*
List any special accommodations necessary for you to participate in this program. Including accessibility requirements, special diet restrictions, respite care, etc.*
Due to Covid-19, Partners may need to go the digital route – for one session, three sessions, or all six. If this is the case, do you have the capability to join via video conferencing? (ie; reliable WIFI)*
Tell us a little about yourself and your family:*
List membership in advocacy organizations and any offices held. (Membership in an organization is not a requirement)*
References
Provide two references (include name, email address, and phone number)
Reference #1: Name*
First Last
Reference #1: Email*
Reference #1: Phone*
Reference #2: Name*
First Last
Reference #2: Email*
Reference #2: Phone*
How did you learn about Partners in Policymaking?*
What type of experience do you have in advocating for children or adults with developmental disabilities, if any?*
Why are you interested in participating in the Partners in Policymaking program?*
Is there a specific area of concern or system change that encourages you to apply to this program?*
What do you hope to accomplish as a result of this program?*
A goal of Partners in Policymaking is to provide the knowledge and resources for participants to work with people who make policy at the local, state, or national level in order to make change. Please list any specific areas or issues you would like to help change.*
My State Senator is:*
First Last
My State Senator's Email:*

(Call their office to obtain direct email address)
My State House Representative is:*
First Last
My State House Representative's Email*

(Call their office to obtain direct email address)
Today's Date*
MM slash DD slash YYYY
Signature*

FLORIDA DEVELOPMENTAL
DISABILITIES COUNCIL

124 Marriott Drive, Suite 203
Tallahassee, Florida 32301
Phone: 850-488-4180
Toll Free: 800-580-7801
TDD Toll Free: 888-488-8633
Fax: 850-922-6702
fddc@fddc.org

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Disclaimer

This project is provided by the Florida Developmental Disabilities Council, Inc., supported in part by grant numbers 1801FLBSDD, 1901FLSCDD-01, and 2001FLSCDD-01 from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.

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