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Nomination/Application for Developmental Disabilities Council Membership

The Council welcomes applications for membership year round.  Council members are appointed by the Governor and serve four year terms.  Whenever there is a vacancy, a membership committee of the Council reviews all the applications received throughout the year and makes recommendations to the full Council for approval.  Names are then submitted to the Governor for his consideration.  The Developmental Disabilities Assistance and Bill of Rights Act of 2000 includes criteria for all states to follow in selecting their DD Councils’ membership and the Louisiana Council takes care to ensure our membership is in compliance with our federal law. 

Download the nomination form below, print it, fill it out and then mail to the address below or submit your information electronically by filling in the form below and clicking the submit button:

Council Membership Nomination Form – pdf 94 kb

Developmental Disabilities Council
P.O. Box 3455
Baton Rouge, LA 70821-3455

Name:
Email:
Date of Birth:
Mailing Address:
City:
Parish:
Zip+4:
Phone: (Home)
(Office)
(Cell)
Best Time to Call:
Employment: Yes  No
Employer:
Occupation:

 

Please select the responses that describe you.

Personal/demographic information: 

Person with a disability   Yes  No

What is the disability? 

Age Disability Began: 

Parent of child (child's age )with disability   Yes  No

What is the disability? 

Age Disability Began

Have you or your son/daughter been determined eligible for services by the Office for Citizens with Developmental Disabilities or the Office of Mental Health?   Yes  No

If yes, list the services eligible to receive (currently receive) 

Please list any waiting lists you or your child are on

Are you an Advocate?   Yes  No

(Needed to comply with our federal law) Please check:

Gender:  Male  Female

Ethnicity:  

    African/American
    American Indian
   Asian/Pacific Islander
    Black (Non Hispanic)
    Hispanic
    White (Non Hispanic)

Please describe your current and past involvements with developmental disabilities issues. Include any organizations to which you belong:

Why do you want to be a member of the Developmental Disabilities Council?

Council meetings begin at 2:00 pm on Wednesday and end around 4:00 pm on Thursday afternoon. Most meetings are held in Baton Rouge. In addition, Council members are involved in committee work and are asked to attend periodic committee and other meetings, averaging about 8 per year, and are involved in Legislative advocacy activities. (Council member travel expenses are reimbursed.)

  yes no

Do you have the time to devote to active Council membership?

  yes no

Do you know of any conflict of interest that would prevent you from serving on the Council? (i.e., are you employed by an agency that receives DD Council funding?)

  yes no

Please specify any possible conflicts:

 

Signature:

Signature Date: 

 

Last Updated: September 24th, 2009 |
Phone: 225-342-6804
Toll Free: 1-800-450-8108
Fax: 225-342-1970
 
Post Office Box 3455
647 Main Street [70802]
Baton Rouge, LA 70821-3455

© 2000 - 2010 Louisiana Developmental Disabilities Council.

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