PIP Application Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Select County*AlachuaBakerBayBradfordBrevardBrowardCalhounCharlotteCitrusClayCollierColumbiaDeSotoDixieDuvalEscambiaFlaglerFranklinGadsdenGilchristGladesGulfHamiltonHardeeHendryHernandoHighlandsHillsboroughHolmesIndian RiverJacksonJeffersonLafayetteLakeLeeLeonLevyLibertyMadisonManateeMarionMartinMiami-DadeMonroeNassauOkaloosaOkeechobeeOrangeOsceolaPalm BeachPascoPinellasPolkPutnamSanta RosaSarasotaSeminoleSt. JohnsSt. LucieSumterSuwanneeTaylorUnionVolusiaWakullaWaltonWashingtonPhone*Email Address* The following questions are designed to ensure diversity in the selection of participants for the FDDC’s Partners in Policymaking™ Advocacy and Leadership Program and are required by the Council's federal funding agency, the Administration on Intellectual and Developmental Disabilities. Your information will not be reported individually; rather, total numbers are submitted for each of these factors.Gender* Male Female Prefer not to answer Ethnicity* White Black or African American American Indian and Alaska Native Hispanic/Latino Asian Native Hawaiian or Other Pacific Islander Two or more races Unknown Are you a person with a developmental disability. If yes, what is your disability? (check all that apply)* Intellectual Disability (Section 393.063(24), Florida Statutes) Autism (Section 393.063(5), Florida Statutes) Spina Bifida (Section 393.063(40), Florida Statutes) Cerebral Palsy (Section 393.63(6), Florida Statutes) Prader-Willi syndrome (Section 393.063(29), Florida Statutes) Down syndrome (Section 393.063(15), Florida Statutes) Phelan-McDermid syndrome (Section 393.063(28), Florida Statutes) Other N/A If other, please specify:*Are there other diagnoses that we should know about (e.g., behavioral health, mental health). If so, please specify:Please select your age range:* 18-24 25-34 35-44 45-54 55-64 65 and over Are you a family member who has decision-making responsibility for their family member with intellectual and developmental disabilities (e.g., parent, sibling, grandparent), or legal guardian of a person with intellectual and developmental disabilities? Please describe your role and if you have more than one child with a developmental disability, please answer for each child.Child’s AgeWhat is your child's developmental disability or disabilities? Check all that apply.* Intellectual Disability (Section 393.063(24), Florida Statutes) Autism (Section 393.063(5), Florida Statutes) Spina Bifida (Section 393.063(40), Florida Statutes) Cerebral Palsy (Section 393.063(6), Florida Statutes) Prader-Willi syndrome (Section 393.063(29), Florida Statutes) Down syndrome (Section 393.063(15), Florida Statutes) Phelan-McDermid syndrome (Section 393.063(28), Florida Statutes) High-risk child (section 393.063(23), Florida Statutes) Other N/A If other, please specify:*Describe how the disability affects your child’s ability to function in major life activities:Does your child live at home?* Yes No N/A If No, Where does your child live?* Supported Living Group Home Intermediate Care Facility (ICF) Planned Residential Community Other If other, please specify:*Tell us a little about yourself and your family:*Describe your child’s school placement, if applicable:Do you have other children? Yes No If Yes, what are their ages?*What services (e.g., supported employment, attendant, respite care, case management) are you or your child currently receiving?*List any special accommodations necessary for you to participate in this program. Including accessibility requirements, special diet restrictions, respite care, etc.*Should Partners need to go the digital route – for one session, three sessions, or all six, do you have the capability to join via video conferencing? (i.e., reliable WIFI)*List membership in advocacy organizations and any offices held. (Membership in an organization is not a requirement)*ReferencesProvide two references (include name, email address, and phone number)Reference #1: Name* First Last Reference #1: Email* Reference #1: Phone*Reference #2: Name* First Last Reference #2: Email* Reference #2: Phone*How did you learn about Partners in Policymaking?*What type of experience do you have in advocating for children or adults with developmental disabilities, if any?*Why are you interested in participating in the Partners in Policymaking program?*Is there a specific area of concern or system change that encourages you to apply to this program?*What do you hope to accomplish as a result of this program?*A goal of Partners in Policymaking is to provide the knowledge and resources for participants to work with people who make policy at the local, state, or national level in order to make change. Please list any specific areas or issues you would like to help change.*The following will have no effect on the selection process.My State Senator is:* First Last My State Senator's Email:* (Call their office to obtain direct email address)My State House Representative is:* First Last My State House Representative's Email* (Call their office to obtain direct email address)Is your child, or are you (if you have a developmental disability), utilizing any of the following healthcare options? Check all that apply.* Medicaid Medicare Private Insurance N/A Are you or your child on one of the following?* iBudget waiver (with the Agency for Person's with Disabilities) CDC+ waiver (with the Agency for Person's with Disabilities) On the waiver waiting list (pre-enrollment category with the Agency for Person's with Disabilities) I have not heard of the Agency for Person's with Disabilities yet N/A If you are not selected for the Partners in Policymaking Program this year, would you still be interested in any of the following engagement opportunities with the Council? Check all that apply.* Serving on an FDDC advisory committee Serving on an FDDC work group Participating in an FDDC research study focus group Having your story or your family member's story highlighted by FDDC Learning more about FDDC events, activities, and trainings Providing input on future planning efforts for work conducted by FDDC N/A Would you like to be added to the FDDC listserv?* Yes No Today's Date* MM slash DD slash YYYY Signature*
