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Your
Name: |
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Address: |
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City: |
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State:
Zip:
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County: |
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Day
phone: |
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Occupation: |
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eMail
Address: |
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Please
click on applicable choices |
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Please check one of these 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 |
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Age
of family member(s):
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Describe
relationship(s) (Sibling, spouse, etc.):
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Please
specify the developmental disability(s) for yourself,
child, or family member:
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Have
you ever applied before? |
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If yes, when:
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Has
anyone in your family participated in Partners in
Policymaking? |
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If yes, who:
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Did he or she graduate?
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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. |
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Why are you interested in the Partners in
Policymaking program? Is there a specific issue
that encourages you to apply?
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What are you most excited about learning through
Partners in Policymaking?
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If you just moved to a new town, how would you
begin to build relationships with others?
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What types of experiences have you had in advocating
for people with disabilities? Please describe in
detail, listing efforts in letter-writing, personal
advocacy, public testimony, other training courses
taken, etc.
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What attributes or qualities do you believe make a
person a good team player?
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What are some of your professional skills, talents
or strengths that you currently have,
that would help to build stronger communities for
people with disabilities?
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What qualities do you have that make you an
effective advocate?
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Please
describe what impact you want to make in the community
and how you see yourself taking what you learn from
Partners in Policymaking back to your community.
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Please
list memberships in advocacy organizations or civic
groups and offices held.
Name of Organization & Office(s) Held &Year
Held
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Please
list the names, addresses and phone numbers of two
individuals who know of your interest in disability
issues. (Name Address Phone Number)
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How
did you learn about Partners in Policymaking?
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PERSONAL
COMMITMENT
The Partners in Policymaking project requires a
significant commitment of time and energy. Participation
involves a two-day program per month from September
2007 through May 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, with a presentation
of the project required at the April or May session.
Please consider your commitment to this project
before applying.
I am committed to attending eight, two-day sessions:
I understand that attendance is mandatory:
I am committed to completing monthly homework assignments:
I understand that completing homework assignments
is mandatory:
internship, letter-writing campaign, etc.):
I understand that completing the major project is
mandatory:
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My
hometown newspaper is (name of publication and
city):
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Please
mail a 1-2 page statement or letter from a leader in
you community, stating why you would make a good
participant in the Partners in Policymaking course.
Mail to:
Atlanta Alliance on Developmental Disabilities
ATTN: Rita Young, Partners in Policymaking
1440 Dutch Valley Place - Suite 200
Atlanta, GA 30324-5371 |
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I will need the following accommodations in order
to participate in Partners in Policymaking.
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Thank you!
(You will then see an on-screen copy of the
information that you sent.) |
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