Partners in Policymaking Application for Participation
Full Name
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Email
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Mailing Address
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City
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State
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Postal code
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Telephone / Contact Number
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Alternate Telephone / Contact Number
Are you a parent of a child or children with developmental disability(ies)?
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Yes
No
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Child or Children's Age(s)
Date of Onset of Child's Disability
Describe the disability and how it affects the ability of your son/daughter to function in at least three of the areas of major life activity ("D" of definition)
What services (school, respite care, case management) is your son/daughter currently receiving?
Describe Your Child's School Placement
Do you have other children?
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Yes
No
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Are you a person with a disability?
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Yes
No
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Your Age
Date of Onset of Your Disability
Briefly Explain Your Disability
Why are you interested in participating in the Partners in Policymaking program?
Is there a specific issue, area of concern, or problem that encouraged you to apply for this program?
Will you make a time commitment of two days (Friday and Saturday), one weekend per month, from November through April? ATTENDANCE AT ALL SESSIONS IS MANDATORY.
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Yes
No
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If employed, will your employer release you to attend Partners sessions?
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Yes
No
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Are there any accommodations necessary for you to participate in this program?
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Yes
No
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Check which of the following accommodations will be necessary for you to participate?
Accessibility
Interpreters
Respite Care
Alternative Formats of Learning Materials
Personal Care Attendant
Other
If you checked 'Accessibility', please describe your needs below.
If you checked 'Personal Care Attendant', please indicate who will be attending with you below.
If you checked 'Other', please specify below.
Do you currently belong to any advocacy organizations?
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Yes
No
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Please list organizations and offices held. Membership is not a requirement.
Please tell us a little about yourself and your family.
Please indicate how you learned about Partners in Policymaking.
Submit