NORTH CAROLINA PARTNERS IN POLICYMAKING 2008 APPLICATION Submit no later than OCTOBER 13, 2007 Partners in Policymaking(tm) is a leadership training program designed for adults with disabilities and parents of young children with developmental disabilities. The program teaches leadership skills, and the process of developing positive partnerships with elected officials and other individuals who make the policy decisions about services that you and your family use. Partners is about systems change - creating, working towards and achieving a vision of shared values about people with disabilities. It is based on the belief that the most effective and enduring public policy decisions are made by the people who need and use services in partnership with elected officials and their policymakers. It is about becoming confident in yourself, competent in the knowledge and information you will receive, and comfortable in sharing the life experiences and expertise you bring to the program. The North Carolina Partners in Policymaking is funded by the North Carolina Council on Developmental Disabilities and is free to participants selected to attend. North Carolina Partners in Policymaking Partners in Policymaking is funded by the NC Council on Developmental Disabilities (NCCDD). 2008 APPLICATION RETURN TO: NC Partners in Policymaking: 3801 Lake Boone Trail, Suite 250, Raleigh, NC 27607 NOTE: This application is available in Braille or on diskette upon request; Contact Jill Rushing at NC Council on Developmental Disabilities 1-800-357-6916 or 919-420-7901 or email partners@nccdd.org. This application is on the Partners website at ncpartnersinpolicymaking.com. Name: _______________________________________________________________________ Address: _____________________________________________________________________ City: _____________________County: _____________Zip Code: ____________________ Day Phone: ____ ____________Evening Phone: ___________________________________ Date of Birth: ____________________________Age: ________ Occupation: ___________________________________ Marital Status: ________________________________ Electronic Mail Address: _________________________________________ ______Male ______Female ______Caucasian ______ African American ______ Latin American ______ Native American ______Asian-Pacific ______Other Origin: ______________________________________ What Language(s) do you speak: _______________________________________________? PLEASE COMPLETE ONE OF THE FOLLOWING THREE CHOICES: ______ A person with a developmental disability. ______ A parent of a person with a developmental disability. Age of Child/Children with disability ___________________________________ ______ A family member, other than parent, of a person with a developmental disability. Age of family member(s) with disability_________________________________ Describe relationship(s) (Sibling, spouse, etc.) __________________________ Please specify the developmental disability (or disabilities) for yourself, child or family member: _____________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________ Have you applied previously to NC Partners in Policymaking? ______Yes ______ No If so, When? _____________________ Have you or a family member participated in Partners in Policymaking in another state? ______Yes ______No If yes, who? ___________________________ Did he or she graduate? _____Yes ______NO North Carolina Partners In Policymaking Please answer all questions to follow that are applicable to you. If you need additional space for your answers please feel free to make attachments as necessary. 1. Why are you interested in the Partners in Policymaking program? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. What do you hope to gain from Partners In Policymaking? ________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ 3. Is there one specific issue, area of concern, or problem that encourages you to apply to this program? ________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ 4. Please describe how disability affects your life, either personally or through a family member with a disability. ________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ 5. What types of experiences have you had in advocating for people with developmental disabilities? Please describe in detail, listing efforts in letter-writing, personal advocacy, public testimony, etc. ________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ 6. Please tell us about yourself and your family. ________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ North Carolina Partners In Policymaking 7. What is your vision for people with disabilities in North Carolina? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ 8. What services are you or your child currently receiving? (For Example: attendant care, respite care, case management, vocational, etc.) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ 9. Please list memberships in advocacy organizations or civic groups and offices held. (For example: Arc; Board Member, PTA; President, etc.) Name of Organization Offices Held & Year Held ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ 10. Please describe what impact you want to make in the community and how you see your self taking what you learn from Partners in Policymaking back to your community. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ ________________________________________________________________________ 11. Please list 2 people who know of your interest in disability issues. (For example: employer, teacher, minister, etc.) A) Name_________________________ B) Name____________________________ Address __________________________ Address___________________________ City_______________________________ City ______________________________ Telephone (____) __________________ Telephone (____) ____________________ Daytime Number (____) _______________ Daytime Number (____) ______________ 12. How did you learn about Partners in Policymaking? ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ 13. My home town newspaper is (name of publication & city):______________________ ________________________________________________________________________ 14. I will need the following accommodations in order to participate in Partners in Policymaking: (For Example: direct support assistance, interpreters, respite care, dietary, transportation, respite, etc.) ________________________________________________ _______________________________________________________________________ _______________________________________________________________________ PERSONAL COMMITMENT The Partners in Policymaking project requires a significant commitment of time and energy. Participation involves a two-day program per month from February 2008 to September 2008. Each month, homework and activity reports are required to be completed and submitted at the next session. In addition, each participant must select a major project to complete during the course of the year. Please consider your commitment to this project before applying. 15. I am committed to attending eight, two-day sessions: ____Yes ____No 16. I understand that attendance is mandatory: ____Yes ____No 17. I am committed to completing monthly homework assignments: ____Yes ____No 18. I understand that completing homework assignments is mandatory: ____Yes ____No 19. I am willing to complete one major project (internship for a public official, letter-writing campaign, research paper, etc.: ____Yes ____No 20. I understand that completing the major project is mandatory: ____Yes ____No Signature of Applicant _________________________Date:______________ RETURN BY October 13, 2007 TO: NC Partners in Policymaking: 3801 Lake Boone Trail, Suite 250, Raleigh, NC 27607 Thank you for your interest in Partners in Policymaking. Please feel free to share copies of this application with anyone who may be interested.