Partners In Policymaking Application

Download the pdf Partners in Policymaking application or fill out the form below.

1. First Name:

Middle Initial:

Last Name:

Address:

Apartment Number:

City:

State/zip:

(Day) Phone #:

(Night) Phone #:

E-mail:

2.Are You?

3.Ethnic Background (optional):

4.Have you applied for a previous Partners' Class?
If Yes, year(s):

To answer questions 5, 6, and 7, see "Developmental Disabilities Defined" in the Partners in Policymaking brochure.

5.Are you a person with a developmental disability?

a. If Yes what is your disability? (birth, age)

b. Your Age

c. Your age at onset of disability?

d. Your birthdate

6.Are you a parent of a person with a disability?

Complete only for a child with a Disability (if there is more than one child with a disability, please provide this information for each child on a separate sheet):

a. Child's Name:
b. Child's Age:
c. Child's Gender:
d. Child's Age at onset of disability?:
e. What is the disability?:
f. What services (school, respite, case management, etc.) is your child currently receiving?

g.Describe the school placement:

h.Does the child live at home?
If not where?

7. Which of the following major life activities is affected by your or your child’s disability:

Self-Care

Receptive and Expressive Language

Learning

Mobility

Self Direction

Capacity for Independent Living

Economic Self-Sufficiency

8. Please list any activity, membership, and offices held in advocacy organizations. (This is not a requirement for participation)

9. Are there any special disability accommodations necessary for you to participate in this program? If yes, please describe them. (accessibility, interpreters, respite, assistance to understand written materials, personal care attendant, or other accommodations)

10. Tell us why you want to participate in Partners in Policymaking?

11. What disability issue/concern is of particular interest to you and what are your ideas to address this issue?

12. Will you make a commitment to attend all 6 weekend sessions in Baton Rouge and complete all homework assignments?:

13. Please list two references

Reference 1
Name:
Address:
City:
State:
Zip:
Day Ph #:
Evening Ph #:

Reference 2
Name:
Address:
City:
State:
Zip:
Day Ph#:
Evening Ph#:

14. Please tell us how you learned about Partners in Policymaking.

15. If anyone helped you prepare this application, please provide his or her name, address, and phone.

Name:
Address:
City:
State
Zip:
Day Phone #:
Evening Phone #:

Last Updated: October 14th, 2007 |

Partners In Policymaking Application

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