NCCDD Council Membership Application (Application Form 1)

Application for Endorsement to the Governor for Appointment
to the North Carolina Council on Developmental Disabilities

(Additionally, Application for Board and Commissions (pdf) required by the Office of the Governor)

APPLICANT NAME:
First Name:
Middle Name:
Last Name:
ADDRESS:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
TELEPHONE:
Home:
Business:
Fax:
E-mail (REQUIRED):

BACKGROUND INFORMATION

This endorsement is for the following category:

	An individual with developmental disabilities/self-advocate (see definition)
	A parent or guardian of child(ren), age 0-21, with developmental disabilities
	An immediate relative or guardian of an adult with developmental disabilities
	An immediate relative or guardian of an adult with a developmental disability who resides, or previously resided, in an institution; or an individual with a developmental disability who resides, or previously resided, in an institution
	Representative of a local and non-governmental agency, or private, not-for-profit group concerned with services to persons with developmental disabilities
	If parent or guardian of a child with a developmental disability, please provide child's age:

Please tell us about yourself/the candidate. Briefly discuss how you/the candidate became interested in disability issues, and present or past involvement in disability advocacy:

DEMOGRAPHIC INFORMATION: (optional)

Date of Birth: 

Sex:  Male Female

ETHNIC GROUP: (This information is helpful in endorsing applicants of culturally diverse backgrounds.) White Black (African American) Hispanic (Mexican, Puerto Rican, Cuban, Central or South American, other) Asian (including Pacific Islander) American Indian (including Alaskan native) Other

I WANT TO BE CONSIDERED FOR ENDORSEMENT TO THE
NC COUNCIL ON DEVELOPMENTAL DISABILITIES BECAUSE:
(What skills and interests would you bring to the Council? Please keep to 1 page.)

POSITION QUESTIONS
(Please give brief answers.)

1. What do you believe are the two or three most important issues for people with developmental disabilities and their families? Please explain.

2. What activities should an organization such as the Council undertake to address these issues?

Please submit this application and other requested material (resumé, vita, or personal/family history, optional) and letters of recommendation by clicking the SUBMIT button below (email address required), or you can print this document and send to the following address:

Melissa Swartz, Quality Improvement Coordinator
NC Council on Developmental Disabilities
3801 Lake Boone Trail, Suite 250
Raleigh, NC 27607
(Voice/TDD) (919) 420-7901
(Toll Free Voice/TDD) (800) 357-6916
(FAX) (919) 420-7917

When you submit an application online, please let us know you have sent it by emailing Melissa Swartz at melissa.swartz@ncmail.net. 

   

Thank you!