INTRODUCTION TO PARTNERS IN POLICYMAKING® How Is Partners in Policymaking® Organized? Partners attend eight, two-day training sessions, in Raleigh, NC. Each session begins at 12:00 p.m. on Saturday and concludes by 3:30 pm on Sunday. National and state leaders in the disability movement present various topics such as: - History of Disability and the Disability Rights Movement - Inclusive Education and Communicating Effectively in Meetings - Supported Employment, Supported Living, Person-Centered Planning - Assistive Technology, Seating & Positioning, Positive Behavior Supports - Federal Policy and Legislative Process - State Legislative Process and Current Issues - State Policy/Service System and Parliamentary Procedures - Community Organization and Local Advocacy Attendance of all eight sessions is mandatory. Partners are expected to complete assignments between sessions and also commit to one major project after graduation. Examples include: serving an internship with a public official, organizing town meetings, coordinating a parent or self-advocacy network or support group, or arranging program visits for legislators. When and Where? Each 2011 session will be held at the Sheraton Raleigh Hotel in Raleigh on the following dates: March 5 & 6 June 25 & 26 April 2 & 3 July 23 & 24 April 30 & May 1 August 27 & 28 June 4 & 5 September 24 & 25 What’s The Cost? This training program is free to participants selected to attend. This includes registration for eight sessions, lodging, transportation, and meals, all arranged by the Partners in Policymaking staff. Funding is available for accommodations as necessary for participation. Partners in Policymaking® is funded by the North Carolina Council on Developmental Disabilities. Application Deadline: December 31, 2010 Applications must be postmarked by midnight, December 31, 2010 Return to: Partners in Policymaking: 3125 Poplarwood Court, Suite 200, Raleigh, NC 27604 Applications are available on the internet and can be downloaded at www.ncpartnersinpolicymaking.com or www.nccdd.org. Please print the application, keep a copy, and return before December 31, 2010. The Partners’ application is also available in Spanish, large print, or audio CD upon request. Any questions may be directed to Freida Moore at the NC Council on Developmental Disabilities 1-800-357-6916 or 919-420-7901 extension 223 or Freida.Moore@dhhs.nc.gov. Keep this page and mail back the remaining pages to: Partners in Policymaking: 3125 Poplarwood Court, Suite 200, Raleigh, NC 27604 Revised 9-13-2010 Page 1 of 5 North Carolina Partners in Policymaking Partners in Policymaking® is funded by the NC Council on Developmental Disabilities (NCCDD). 2011 APPLICATION RETURN TO: NC Partners in Policymaking: 3125 Poplarwood Court, Suite 200, Raleigh, NC 27607 NOTE: This application is available in Braille or on CD upon request; Contact Freida Moore at NC Council on Developmental Disabilities 1-800-357-6916 or 919-420-7901 extension 223 or email Freida.Moore@dhhs.nc.gov. This application is also on the Partners’ website at www.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 Revised 9-13-2010 Page 2 of 5 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. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Revised 9-13-2010 Page 3 of 5 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 ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 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®? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Revised 9-13-2010 Page 4 of 5 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 March 2011 to September 2011. 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 (examples: 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 Partners in Policymaking® is not an entitlement program. Participation in the program is highly competitive and spaces are limited. If you are accepted to be a participant in the 2011 class of Partners in Policymaking®, it is expected that you will attend and actively participate in each and every session. Failure to fulfill the terms and conditions of this training program will result in your being asked to leave the program. I have read and understand the foregoing admonishment and agree to govern myself accordingly. Signature of Applicant _________________________ Date: ______________ RETURN BY December 31, 2010 TO: NC Partners in Policymaking: 3125 Poplarwood Court, Suite 200, Raleigh, NC 27604 Thank you for your interest in Partners in Policymaking®. Please feel free to share copies of this application with anyone who may be interested. Revised 9-13-2010 Page 5 of 5