MINNESOTA PARTNERS IN POLICYMAKING®
2016-2017 APPLICATION FOR PARTICIPATION

CLASS 34

September 9-10, 2016
October 21-22, 2016
November 18-19, 2016
January 6-7, 2017
February 17-18, 2017
March 5-6, 2017
April 7-8, 2017
May 12-13, 2017

APPLICATION DEADLINE IS JULY 11, 2016
Applicants will be notified by August 15, 2016 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 particularly 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.
Cell Phone: Please include area code.
Email:

1. Are you a person with a disability?

Yes       No. (If no, proceed to Question 2.)

If yes, please specifiy your disability and provide information about how it affects your daily life.

 

 

 

What kinds of support services or technology services/devices do you use or do you receive?



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

Yes       No. (If no, proceed to Question 3.)
If yes, check one in each column for each child with a developmental disability:
Age
Child #1

Birth - 3
3 - 7
7 - 10
10 - 14
14 - 18
Age
Child #2

Birth - 3
3 - 7
7 - 10
10 - 14
14 - 18
Age
Child #3

Birth - 3
3 - 7
7 - 10
10 - 14
14 - 18
Age
Child #4

Birth - 3
3 - 7
7 - 10
10 - 14
14 - 18
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 specify, by child his/her disability(ies) and provide information about how it affects his/her daily life and that of your family.
Please provide some specific information on how your child's disability affects your ability to access necessary or needed services.
Is your son/daughter receiving special education services? Yes       No
If yes, please describe those services.

What services do you, your family, or your son/daughter receive from the county where you live?

 


3. 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


4. Identify one or two specific disability-related problems (such as waiver services, school inclusion, competitive work) that are of greatest concern to you.

5. Weekend sessions begin with check-in and lunch on first day at 11:00 a.m. and end on the 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 (September through May with no session in December), for eight months? Yes No

Please place the session dates on your calendar at this time.

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

6. If you have a disability, what accommodations do you need to help you actively participate in the weekend sessions (such as wheelchair access or larger print)?

7. Do you require interpreter services (such as sign language or other language translation)?
Yes No
 If yes, please specify:

8. 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 accompanied by your personal care assistant (PCA) during the weekend sessions? (Partners cannot provide PCA services.) Yes No

PLEASE NOTE: The Partners program does not provide on-site respite/child or personal care attendent services, but reimbursement for the cost of these services (up to a maximum of $190/weekend) will be provided if no other source of funds is available to you.


9. Are you currently a member of, do volunteer work for, or are involved with an advocacy organization? Yes No
   
If yes, what is the organization(s) and what role(s) do you play?

10. Please tell us about yourself/your family.

a. If you are working, tell us about where you work, the job you have, full time or part time, etc.

b. If you are in school, tell us about your degree program or the classes you are taking.
c. In what community/volunteer activities are you involved?
d. What are some of your personal interests?
e. Please share any life experiences that have been particular joys or challenges for you, your child or your family.

11. Tell us why you want to participate in the Partners in Policymaking program.

12. How did you learn about the Partners in Policymaking program?
Please include the names of people or organizations that told you about Partners. We want to evaluate our recruiting efforts, find out what approaches work best, and how Partners graduates across the state are assisting with recruitment.

This form is designed for online submission and cannot be saved. Before submitting this form you should 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.

All online applications will receive an acknowledgement via U.S. mail. If you do not receive a response within 14 business days, assume your submission did not go through and re-submit.

Inquiries about the Partners in Policymaking program should be directed to:

GTS Educational Events, 2233 University Avenue W, Suite 150, St. Paul, MN 55114
Dolly Parker- dparker@mngts.org
Phone: 952-885-8085 (metro) or 800-569-6878 ext. 205 (non-metro)
Fax: 651-223-5307