Arkansas Governor's DD Council

Family Leadership Training Program
Partners in Policymaking

Application for Participation

(To move between fields, please use your tab button on your computer)

Applicant Name:
Date: (mm/dd/yyyy)
Individual/ Parent/Guardian:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Message:
E-Mail:
Sex:	Male Female
Age:
Race:

Definition of Developmental Disabilities
The term developmental disabilities means a severe chronic disability of a person five years of age or older which is (A) attributable to a mental or physical impairment or a combination of a mental and physical impairments; (B) manifested before the person attains age twenty-two (22); (C) likely to continue indefinitely; (D) results in substantial functional limitations in three or more of the following major life activity - self-care, receptive and expressive language, learning, mobility, capacity for independent living, self-direction and economic self-sufficiency and (E) reflects the person's need for a combination and sequence of special, interdisciplinary or generic care, treatment or other services which are of lifelong or extended duration and are individually planned and coordinated; except that such term when applied to infants and young children means individuals from birth to age five (5) inclusive, who have a substantial developmental disability or specific congenital or acquired conditions with high probability of resulting in developmental disabilities if services are not provided.

Tell us a little about yourself and your family.

Why do you wish to participate in this project?

Please list any previous or present advocacy experience.

Describe a recent experience that illustrates your creativity or flexibility in approaching or solving service delivery issues for you, a family member or another person for whom you were advocating.

Advocacy can be a long process. Describe an experience you have had that reflects your determination, tenacity and perseverance.

If selected for Family Leadership, what would you like to see change in the current service delivery system (describe either a personal issue or a larger issue that would affect all). Please be specific and give details.

What unique experiences, perspectives, talents or skills could you bring to Family Leadership?

List activities in which you regularly participate (employment, volunteer work, community service, Board assignment, etc.) that would demonstrate your commitment to completion of a project and illustrate your dedication to empowering individuals with disabilities.

What do you hope to accomplish from Family Leadership?

How did you learn about this training program?

Are you the parent of a child with a developmental disability?
Yes No

If yes, please indicate if you are the:
Father Mother Legal Guardian

Age and brief information about your child/children with a disability(ies):

Does the definition of “Developmental Disability” listed at the top of this application apply to you or your child?
Yes No

If the definition of” Developmental Disability” does not apply to you or your child, but there is a disability, please describe briefly:

Please list two references. Each person listed must complete and submit the required letters of recommendation. The (Reference Form) is available in an Acrobat Reader (pdf) format and can be printed and given to the persons listed as references. Letters should be mailed within two weeks following submission of this application to the DD Council.

Name:
Phone:
e-mail address:

Name:
Phone:
e-mail address:

Application Checklist
Did you remember to do these things?

Complete ALL sections of this application. Applications with incomplete sections and background information may NOT be considered.
Letters of recommendation must be received by the DD Council no later than two weeks after you submit this application.

Electronic Signature:

Family Leadership/Partners in Policymaking (FLP) participants are parents of individuals with developmental disabilities. Individuals participating in the program will receive advocacy, resource development and skill building training. Completion of this application and subsequent selection for the Family Leadership/Partners in Policymaking program requires a substantial commitment of time, motivation and energy. I understand that if I am accepted, the FLP Program requires me to attend and participate in ALL of the two-day sessions between January and July. Each session begins Friday morning and concludes Saturday at Noon. I agree to complete all homework and class assignments. All of the information provided in this application is correct.

By typing in my name, I agree to the terms listed above: