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 Partners in Policymaking Application

Partners in Policymaking is a leadership program for adults with developmental disabilities and parents of young children with developmental disabilities. Partners become familiar with the policymaking and legislative process at the local, state and federal levels. The program teaches skills necessary for individuals to become advocates who can influence the system of services for people with developmental disabilities.

Please provide the following information:

Name: *

Date of Birth: *
Select a date from the calendar.
Address: *

City:

State:

Zip Code:

County: *

Work Phone:

Home Phone:

Email:

Date:
Select a date from the calendar.

The term developmental disability is defined as a severe, chronic disability is attributable to a mental or physical impairment, or combination of mental and physical impairments; manifested before the individual attains age 22; is likely to continue indefinitely; results in substantial functional limitations in 3 or more of the following areas of major life activity: (1) Self-care; (2) Receptive and expressive language; (3) Learning; (4) Mobility; (5) Self-direction; (6) Capacity for independent living; (7) Economic self-sufficiency; and reflects the individual’s need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated. A child from birth through age 9 who has a substantial developmental delay or specific condition either from birth or acquired, may be considered to have a developmental disability without meeting 3 or more of the criteria described in (D) (a) through (g) if the child, without services and supports, has a high probability of meeting those criteria later in life.

Are you a person with a Developmental Disability? *

What is your disability? *

Age of onset? *

Please provide any additional information you wish to share about your disability. *

Choose one of the following options: *

Are you a parent/guardian of a young child with a developmental disability?

Age of onset? *

Current age of son/daughter? *

Describe your family member's disability: *

Does your son/daughter live at home?

What services are you or your child currently receiving (employment, respite, case management, personal assistant service, etc.)? *

Why are you interested in participating in the Partners in Policymaking program? *

Is there a specific issue, area of concern, or problem that encourages you to apply for this program? *

What would life be like for you or your family member if the world was a better place for people with disabilities? *

Will you make a commitment to attend the eight 2-day sessions (Friday & Saturday) the months of September through May?

Will you travel to Charleston to attend the scheduled meetings? (Meals and lodging will be provided. Costs for transportation, personal assistant service, respite, and child care will be covered upon request).

Will you make a commitment to complete homework assignments between sessions?

Please list your membership in any advocacy organizations and indicate any office held. (Membership in organizations is not a requirement.)

What types of experience have you had in advocating for people with developmental disabilities? *

How did you hear about the Partners in Policymaking class? *

Who are two people we may contact for references? Please include name, address, and phone number. *

Please also include emails (if available).
Attachments

TO BE CONSIDERED FOR THE PARTNERS IN POLICYMAKING PROGRAM, APPLICANTS MUST ANSWER ALL OF THE QUESTIONS ON THE APPLICATION!
If you need this application in an alternative format or you have any questions please contact the WV DD Council at 304-558-0416 or christy.d.black@wv.gov

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