Partners in Policymaking Application for Participation

Full Name *

Email *

Mailing Address *

City *

State *

Postal code *

County *

Telephone / Contact Number *

Alternate Telephone / Contact Number

Are you a parent of a child or children with developmental disability(ies)? *

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? *

Are you a person with a disability? *

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. *

If employed, will your employer release you to attend Partners sessions? *

Are there any accommodations necessary for you to participate in this program? *

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? *

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.