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Application for Participation

Year 30 Training Dates:

November 5-6, 2021AmericInn, Ft. Pierre, SD -- Person Centered Thinking/History/People 1st Language
December 10-11, 2021 - AmericInn, Ft. Pierre, SD -- Special Education/Inclusion
January 20-22, 2022 - Governor's Inn, Pierre, SD -- Legislature
February 11-12, 2022 - AmericInn, Ft. Pierre, SD -- Local Gov't/Asst. Technology/Time Management/Assertiveness/Effective Meetings/Talking Circle
March 18-19, 2022 - Governor's Inn, Pierre, SD -- Social Security; Abuse/Neglect
April 22-23, 2022 - Ramkota Hotel, Sioux Falls, SD -- Employment/Inclusive Community

YEAR 30 APPLICATIONS ARE DUE NO LATER THAN SEPTEMBER 25, 2021

A word document version of this application can be found at the following link: Year 30 Partners Application - Word Document

Name: *
 
Email Address: *
 
Mailing Address: *
 
City: *
 
State: *
 
Zip Code: *
 
County: *
 
Home Phone: *
 
Work/Alternative Phone:
Question 1
(click here to see definition of developmental disabilities)
Are you a parent of a son or daughter with a developmental disability?: *
 
If Yes, child/children ages:
Date of onset of child's disability:
Describe the disability and how it affects the ability of your son/daughter to function in at least three of the areas of major life activity ("D" of definition):
What services (school, respite care, case management) is your son/daughter currently receiving?:
Describe your child's school placement:
Question 2
Do you have other children?: *
 
Question 3
Are you a person with a disability?: *
 
Your Age:
Date of onset of disability:
Briefly explain your disability:
Question 4
Why are you interested in participating in the Partners in Policymaking program?:
Is there a specific issue, area of concern, or problem that encouraged you to apply for this program?:
Question 5
Will you make a time commitment of two days (Friday and Saturday), one weekend per month, from November 2021 through April 2022? ATTENDANCE AT ALL SESSIONS IS MANDATORY.: *
 
If employed, will your employer release you to attend Partners sessions?: *
 
Question 6
Are there any accommodations necessary for you to participate in this program?: *
 
If Yes, check which of the following accommodations will be necessary for you to participate?:





If Accessibility, please describe your needs:
If Personal Care Attendant, please indicate who will be attending with you:
If Other, please specify:
Question 7
Do you currently belong to any advocacy organizations?: *
 
If Yes, please list organizations and offices held. Membership is not a requirement.:
Question 8
Please tell us a little about yourself and your family:
Please indicate how you learned about Partners in Policymaking:
Letter of Recommendation
A letter of recommendation must accompany this application.

Letter of Recommendation form can be found here.