Oregon Partners in Policymaking

Application deadline: postmarked by November 23, 2007

Electronic form notes:

To move between fields, use the "tab" key or click in the next box; if you hit "enter" or "return" the system will submit your incomplete form before you reach the bottom of the page.

Upon submission you will see a thank you page, and you will receive an email confirmation when we have received your application. If you do not receive a confirmation within 72 hours, please contact us to confirm receipt of your application.

Female
Male

To assure cultural diversity, the following information is requested. Your response is optional:

Asian/Pacific Islander
African American
American Indian/Alaskan Native
Latino
Caucasian
Other

I am a person with a developmental disability.

If so, please describe your disability and how it affects your daily life:
Please enter information here ONLY if you are a person with a disability. If you are the parent of a child with a disability, please see below.

What kind of work/school are you involved in?
(Include volunteer work, home-making, etc., not just paid work.)

Please continue with question number 1, below.

OR

I am the parent of a child with a developmental disability.

Son/daughter, age(s):
Non-disabled sibling, age(s):
Does your child live at home? Yes No

Please describe your child’s disability. How does it affect family life?

Describe your child's school placement/program:

ALL APPLICANTS: Please answer all questions. Feel free to take as much space as you need; a large box for additional comments is at the bottom of the application.

1. Please list 3 words that reflect how you value people who have disabilities:
a.
b.
c.

2. Please tell us a little about yourself and your family, and why you are interested in Partners.

3. Please describe your experiences in advocating for yourself, your child or others with developmental disabilities.

4. Which advocacy or disability-related organizations do you participate in? In what capacity?

5. What are your "burning issues" around the disabilities service system, healthcare, and/or the education system?

6. What supports do you/your family receive (employment, attendant, respite care, case management, etc.)?

7. What do you hope to do after you complete the Partners Class?

If selected to participate in the Oregon Partners in Policymaking Class of 2008, I will:
Commit to attend ALL two-day sessions in Salem, from 1pm Friday to 4pm Saturday: (See calendar for dates)
Yes No
Make arrangements with my employer, family and friends, as needed, to fully participate:
Yes No
Complete all homework assignments, i.e., community networking, advocacy activities, reading:
Yes No

Special accommodations needed to participate fully in this program:

Physically-accessible lodging*
Accessible transportation*
Personal assistant
Childcare stipend
Interpreter
Materials in alternate format
Homework assistance
Other

*All participants are provided lodging in the hotel, and mileage reimbursement or other transportation arrangements. Please check box if your lodging or transportation needs involve physical accessibility or additional supports.

Please provide two references - name, address, phone number and email for each:

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