2008PartnersCAApplication

Instructions

Application Deadline: January 16, 2008

Partners in Policymaking
c/o The Arc of California
1225 8th Street, Suite 210
Sacramento CA 95814

If you have any questions while filling this application, please call Jordan Lindsey at 1-800-698-6619 or email him at jlindsey@arccalifornia.org.

Please provide the following (*required)

First Name*

Last Name*

Address*

City*

State / Province*

Zip*

Day Phone*

Email*

Evening Phone*

About You

Are you:

	Female
	Male

2.	What is your ethnic background? (optional)

	Asian
	African American
	Caucasian
	Hispanic
	Pacific Islander
	Other:

3.	What is your educational background?

	(Select all that apply.)
	High school, no diploma
	High school graduate of equivalent (GED)
	Some college
	Associate degree (AA, AS)
	Bachelor's degree
	Vocational training (describe below)
	Master's or Professional degree
	Other:

4.	If you checked Vocational Training, please describe:

5.	What is your disability or the disability of your child?

6.	What is your age or the age of your child?

7.	Would you need wheelchair accessibility to participate?

	Yes
	No

8.	Would you need an interpreter to participate?

	Yes
	No

9.	If yes, what language?

10.	Do you or your child receive Regional Center services?

	Yes
	No

11.	If yes, which Regional Center?

	Valley Mountain
	Central Valley
	Kern
	San Andreas
	Tri-Counties

Other Questions

12.	How did you hear about Partners in Policymaking?

13.	Why are you interested in participating in Partners in Policymaking? What do you hope to accomplish by becoming a Partner?

14.	Is there a specific issue, area of concern, or challenge that encourages you to apply for Partners?

15.	Experience in leadership activities is not a requirement of this program, but please list any leadership experience, organizations which you are involved in, and any office held.

16.

Involvement in advocacy is not a requirement of this program, but please describe any experience you have advocating for yourself or others with developmental disabilities (for example: Talking with public officials, talking with teachers or service providers, working to improve schools, public speaking, etc.).

17.

Please submit one to two letters of recommendation OR contact information for two people who can tell us why you'd be a successful Partners participant (letters of recommendation are preferred).

If you are submitting letters of recommendation, you can either mail them to:

Partners in Policymaking, c/o The Arc of California
1225 8th St, Ste 210
Sacramento CA 95814.

Or you can email the letters to jlindsey@arccalifornia.org.

If you are submitting contact information for two people, please enter their names and phone numbers or email addresses below:

18.	If you are selected, you will be asked to check your email at least once a week. This will require Internet access. Will you be able to get Internet access?

	Yes
	No

19.	If yes, describe how:

	Home computer
	Work Computer
	Library computer
	Friend's computer
	Other:

20.	If selected, you will be required to be away from home for 2 days and 1 night each month for 8 months. Will you commit to this? (Missing a session may result in dismissal from Partners.)

	Yes
	No

21.	There will be assignments, approximately 2-4 hours per month to complete between sessions. Will you commit to complete the assignments?

	Yes
	No

22.	Did you have assistance filling out this application?

	Yes
	No

23.	If yes, please fill in the name of who assisted you, and how they helped you:

Thank You

Application deadline is Wednesday, January 16, 2008.