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Application for Participation

Year 28 Training Dates:
November 15-16, 2019- Governors Inn. Pierre, SD -- History/People 1st Language/Person Centered Thinking
December 13-14, 2019-- Governors Inn. Pierre, SD --Inclusive Education/IDEA
January 23-25, 2020-- Governors Inn. Pierre, SD --Legislature
February 7-8, 2020-- Governors Inn., Pierre, SD --Local Gov't/Asst. Technology/Self-Advocacy/Meetings
March 13-14, 2020-- Governors Inn. Pierre, SD --Social Security, Abuse/Neglect
April 22-26, 2020-- Best Western Plus Ramkota Hotel, Sioux Falls,SD--Employment/Inclusive Community

YEAR 28 APPLICATIONS ARE DUE SEPTEMBER 30, 2019

Name: *
Email Address: *
Mailing Address: *
City: *
State: *
Zip Code: *
County: *
Home Phone: *
Work/Alternative Phone:
Question 1 (click here to see definition of developmental disabilities)
Are you a parent of a son or daughter with a developmental disability?: *
If Yes, child/children ages:
Date of onset of child's disability:

Describe the disability and how it affects the ability of your son/daughter to function in at least three of the areas of major life activity ("D" of definition):

What services (school, respite care, case management) is your son/daughter currently receiving?:

Describe your child's school placement:
Question 2
Do you have other children?: *
Question 3
Are you a person with a disability?: *
Your Age:
Date of onset of disability:

Briefly explain your disability:
Question 4
Why are you interested in participating in the Partners in Policymaking program?:

Is there a specific issue, area of concern, or problem that encouraged you to apply for this program?:
Question 5
Will you make a time commitment of two days (Friday and Saturday), one weekend per month, from November 2019 through April 2020? ATTENDANCE AT ALL SESSIONS IS MANDATORY.: *

If employed, will your employer release you to attend Partners sessions?: *
Question 6
Are there any accommodations necessary for you to participate in this program?: *
If Yes, check which of the following accommodations will be necessary for you to participate?: Accessibility Interpreters Respite Care Alternative formats of learning materials Personal Care Attendant Other

If Accessibility, please describe your needs:
If Personal Care Attendant, please indicate who will be attending with you:
If Other, please specify:
Question 7
Do you currently belong to any advocacy organizations?: *
If Yes, please list organizations and offices held. Membership is not a requirement.:
Question 8
Please tell us a little about yourself and your family:

Please indicate how you learned about Partners in Policymaking:
Letter of Recommendation
A letter of recommendation must accompany this application. Letter of Recommendation form can be found here.

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Application for Participation