Advocates In Action
This program is implemented by The Arc of
Kentucky, Inc.
Application for Participation
Name of Applicant __________________________________________________________________
Address__________________________________________________________________________
City____________________________State__________________________Zip Code_____________
Daytime Telephone_________________________Evening Telephone___________________________
Fax_______________________________________E-mail__________________________________
Participant Information
(Mark all that is applicable to you)
| 1. | Are you a person with a developmental disability | _____ |
| parent of person with a disability | _____ | |
| family member | _____ | |
| professional working with people with disabilities? | _____ |
2. Male _____ Female _____ Age (optional)____________
3. Primary Language_________________________
| 4. | Ethnic Heritage | _____ |
| African American | _____ | |
| Asian | _____ | |
| Hispanic | _____ | |
| Native American | _____ | |
| White | _____ | |
| Other | _____ |
5. Describe your own disability, your child's disability, your sibling/family
member's disability
or the disability of individuals with whom you work.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
6. What type of experience have you had as a self-advocate, family member, sibling or professional
or advocate others with a developmental diability?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
7. What current services are you, your child, or sibling/family member receiving?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
8. Are you familiar with services that are available? Yes_____ No_____
If no, do you want to know more about services that are available? Yes_____No___9. Why are you interested in participating in the Advocates in Action Project? Is there a specific
concern, issue, or problem that encourages you to apply for this project? _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
10. Please explain how you would use your advocacy training in the future.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
11. Please list any advocacy organizations in which you have participated, and decribe
your involvement.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
12. Please indicate how you learned about the Advocates in Action Self-Determination/Leadership
Training Project.
________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
13. Are specific accommodations (such as transportation, diet, interpreter, materials in
alternative formats, such as braille, large print, etc.) needed for you to participate in thi project?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
14. Please list two individuals who would recommend you for this project
(include name, address and telephone)
(1) ______________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
(2) ______________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
PLEASE NOTE: A commitment to attend at least two 2-day training sessions in required to be included
in the project. Emergency situations will be taken into account.
_______________________________________
Signature of Applicant
|
Please mail completed form to: |
|
Patty Dempsey, Executive Director |
|
The Arc of Kentucky, Inc. |
|
706 E. Main Street, Ste A |
|
Frankfort, Kentucky 40601 |
The person you receive this application from may assist you
in completing it, if you need assistance.
For additional information or assistance
from The Arc, please feel free to contact
Patty Dempsey at The Arc office
1-800-281-1272 or 502-875-5225 or e-mail ArcofKY@aol.com
(Printed with funds through the Cabinet for Health &Family Services)