NCCDD - NCCDD Council Membership Application

NCCDD Council Membership Application

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:

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Middle Name:

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Last Name:

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ADDRESS:

Address Line 1:

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Address Line 2:

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City:

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State:

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Zip Code:

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TELEPHONE:

Home:

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Business:

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Fax:

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E-mail:(*Required)

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BACKGROUND INFORMATION

This endorsement is for the following category:

An individual with developmental disabilities/self-advocate (see definition)

A parent or guardian of children, 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

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If parent or guardian of a child with a developmental disability, please provide child's age:

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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:

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DEMOGRAPHIC INFORMATION: (optional)

Date of Birth:

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Sex:

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ETHNIC GROUP: (This information is helpful in endorsing applicants of culturally diverse backgrounds.)

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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.)

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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.

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

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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:

(*Required)

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David Ingram, Director of Operations NC Council on Developmental Disabilities
2010 Mail Service Center Raleigh, NC 27699-2010
(Voice/TDD) 984-920-8200
(Toll Free) (800) 357-6916
(FAX) (984)-920-8201

When you submit an application online, please let us know you have sent it by emailing Cora Gibson at [email protected]

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