MINNESOTA PARTNERS IN POLICYMAKING®
2008-2009 APPLICATION FOR PARTICIPATION

CLASS 26

September 19-20, 2008
October 24-25, 2008
November 21-22, 2008
January 23-24, 2009
Febrary 13-14, 2009
March 29-30, 2009
April 24-25, 2009
May 15-16, 2009

APPLICATION DEADLINE IS JULY 25, 2008
APPLICANTS WILL BE NOTIFIED ABOUT SEPTEMBER 5, 2008
REGARDING THEIR APPLICATION STATUS.

TENNESSEN WARNING

PLEASE NOTE: The information requested on this application is for the purpose of selecting individuals who meet the criteria for participation in the Partners in Policymaking program. The list of names and addresses of Partners graduates that is prepared for each Partners class is taken from the applications and considered public data under the Minnesota Government Data Practices Act. This list may be requested and will be released upon request.

Definition of "Developmental Disability"

The term "developmental disability" means a severe, chronic disability of an individual 5 years of age or older that

a. is attributable to a mental or physical impairment or a combination of mental and physical impairments;

b. is manifested before the individual attains age 22;

c. is likely to continue indefinitely;

d. results in substantial functional limitations in three or more of the following areas of major life activity:

  • self care
  • receptive (understanding) and expressive language
  • learning
  • mobility (ability to move)
  • self direction (motivation)
  • capacity for independent living
  • economic self sufficiency; and

e. reflects the individual’s need for a combination or sequence of special, interdisciplinary, generic services, individual supports or other forms of assistance which are of a lifelong or extended duration and are individually planned and coordinated;

f. an individual from birth to age nine, inclusive, who has substantial developmental delay or specific congenital or acquired condition, may be considered to have a developmental disability without meeting at least three of the above "areas of major life activities," if the individual, without services and supports, has a high probability of meeting those criterias later in life.

PLEASE NOTE: This application is for Minnesota applicants only. We are particulary looking for applicants from the counties of Lac Qui Parle and Wabasha.

WARNING: Hitting "Enter" key on your keyboard will submit the application. If this happens please reapply.

Name:
Street Address:
City:
County:
State:
Zip Code:
Home Phone: Please include area code
Work Phone: Please include area code
Email:
Fax: Please include area code

1. Are you a person with a disability?
Yes       No

If so, tell us how your disability affects what you can do and how you do things:

 

 

 

Please also tell us what kinds of support services or technology services/devices you use or receive.

2. Are you a parent of a child with a developmental disability?

 Yes       No
If no, go to question #4.
If yes, what services do you, your family, and/or your son/daughter receive from the county in which you live?
Check one in each column for each child with a developmental disability:
Age
Child #1
Birth - 3
 3 - 7
 7 - 10
 10 - 14
 14+		 Age
Child #2
Birth - 3
 3 - 7
 7 - 10
 10 - 14
 14+		 Age
Child #3
Birth - 3
 3 - 7
 7 - 10
 10 - 14
 14+
Age
Child #4
 Birth - 3
 3 - 7
 7 - 10
 10 - 14
 14+
Disability
Child #1
Physical
Cognitive
Emotional/
   Behavioral
Sensory
Other		 Disability
Child #2
Physical
Cognitive
Emotional/
   Behavioral
Sensory
Other		 Disability
Child #3
Physical
Cognitive
Emotional/
   Behavioral
Sensory
Other
Disability
Child #4
Physical
Cognitive
Emotional/
   Behavioral
Sensory
Other
Please provide information concerning your son/daughter's diagnosis that you believe would be helpful in evaluating your class application.
3. Is your son/daughter receiving special education services? Yes       No
If yes, describe some of those services.

4. Do you, or does your son/daughter, meet the federal definition of a person with a developmental disability?
(See definition at the top of this application.)		 Yes       No

5. What problems or issues are of the greatest concern to you?

6. Weekend sessions begin with check-in and lunch on first day at 11:00 a.m. and end on second day at 3:00 p.m. They are held at the Minneapolis Airport Marriott in Bloomington. Double occupancy rooms (you will be roomed with another class member) and meals will be provided.

a. Attendance is required at each weekend session. Will you make a time commitment of two days, one weekend a month, for eight months? (September through May with no session in December) Yes No

Please put the session dates on your calendar now.

b. If you are employed, have you talked with your employer about session attendance and made necessary arrangements so you can attend all weekend sessions?

 Yes No
7. If you have a disability, what accommodations do you need? (such as wheelchair access or larger print and so on)
8. Do you require interpreter services? (such as signing or language translation) Yes No
 If yes, please specify:
9. If you are a parent, will you be using respite/child care services, so you can participate in the Partners program? Yes No
 
If you are a person with a disability, will you be using personal care attendant services during the weekend sessions? Yes No

PLEASE NOTE: The Partners program does not provide on-site respite/child or personal care attendent services, but reimbursement toward these costs will be provided if no other source of funds is available to you.

10. Are you currently involved with an advocacy organization? Yes No
   
If yes, what organization(s) and what role(s) do you play?

11. Please tell us about yourself/your family.

a. If you are working, tell us about your job and the kind of work you do.
b. If in school, tell us about your field of study or the types of classes you are taking.
c. In what type of community/volunteer activities are you involved in?
d. What are some of your personal interests?
e. Please share any life experiences that have been special joys or challenges for you, your child or your family.
12. Tell us why you would like to participate in the Partners in Policymaking program.
13. How did you learn about the Partners in Policymaking program?

 

Inquiries about the program should be directed to:

Government Training Services
2233 University Avenue W.
St. Paul, MN 55114
651-222-7409, ext. 205 (metro)
651-223-5307 Fax
800-569-6878 ext. 205 (non-metro)
cschoeneck@mngts.org

This form is designed for online submission and cannot be saved. Before submitting this form you may print it out for your records. PLEASE NOTE: Any text entered that is not visible in the field will not print but will be included on your submitted form. Additional information about this application appears below.

All online applications will receive an acknowledgemen via U.S. mail. If you do not receive a response within 5 business days, assume your submission did not go through and please re-submit.