Partners in Policymaking is an initiative of the Louisiana Developmental Disabilities Council. Partners is a comprehensive leadership training program that will enable participants to maximize their abilities to advocate for appropriate supports and services designed to increase the self-determination, independence, productivity, and full inclusion of people with developmental disabilities in all facets of community life in Louisiana.

Partners in Policymaking participants and graduates are people with developmental disabilities* or parents of young children with developmental disabilities with a desire to improve and expand the system of supports that enable persons with developmental disabilities to be fully included in their communities. Program participants attend and participate in six two-day advocacy training and skill building workshops. These sessions run between January and June. Completion of this application and selection for the Partners in Policymaking program requires a substantial commitment of time, motivation, and energy.

Class Schedule

Session 1: January

Session 2: February

Session 3: March

Session 4: April

Session 5: May

Session 6: June

Weekend sessions begin with check-in at 12:00 p.m. on the first day and end at 3:00 p.m. on the second day. Double occupancy rooms (you will be roomed with another class member) and meals will be provided. Sessions are held at Embassy Suites, 4914 Constitution Avenue, Baton Rouge, LA 70808.

Applicants must complete ALL sections of the PIP application and submit it to the Council office no later than September 30^th to be considered for next year’s class.

Applications may be submitted through the online application or by e-mail, fax, or U.S. Mail.

If you have any questions or need assistance or accommodations to complete this PIP application form, please contact the Louisiana Developmental Disabilities Council as indicated on the last page of this application form.

*Applicants or their child must have a developmental disability according to the definition included in the Developmental Disabilities Assistance and Bill of Rights Act of 2000, PL106-402.

Definition of Developmental Disabilities

Please review the federal definition of Developmental Disabilities

(A) IN GENERAL- The term `developmental disability’ means a severe, chronic disability of an individual that–

(i) is attributable to a mental or physical impairment or combination of mental and physical impairments;

(ii) is manifested before the individual attains age 22;

(iii) is likely to continue indefinitely;

(iv) results in substantial functional limitations in 3 or more of the following areas of major life activity:

Self-care.
Receptive and expressive language.
Learning
Mobility
Self-direction
Capacity for independent living
Economic self-sufficiency and

(v) reflects the individual’s need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated.

(B) INFANTS AND YOUNG CHILDREN-An individual from birth to age 9, inclusive, who has a substantial developmental delay or specific congenital or acquired condition, may be considered to have a developmental disability without meeting 3 or more of the criteria described in clauses (i) through (v) of subparagraph (A) if the individual, without services and supports, has a high probability of meeting those criteria later in life.

Application for Participation

Attendance is required at each weekend session. Will you make a time commitment of two days, one weekend a month (January through June), for six months?*
- Yes
- No
PIP Application
Name*
First Last
Address*
Street Address City ZIP Code
Home Phone*
Cell Phone
Email*
Enter Email Confirm Email
Demographics
1. Gender*
- Male
- Female
2. Ethnic Background
- African American
- Caucasian
- Hispanic
- Asian - Pacific Islander
- American Indian
3. Have you applied for a previous Partners' class?*
- Yes
- No
If yes, year(s):
4. Are you a PERSON with a developmental disability?*
- Yes
- No
If you answered YES, please answer the following
Age Disability/Diagnosis Your age at onset of disability
5. Are you a PARENT of a YOUNG CHILD with a developmental disability?*
- Yes
- No
COMPLETE ONLY FOR YOUR CHILD WITH A DEVELOPMENTAL DISABILITY:
If there is more than one child with a developmental disability, please click the plus (+) beside the question to add each additional child
Child's information
Name Age Disability/Diagnosis Gender Age at onset of disability Does your child live at home with you? If not, where?
6. Check how the disability affects your child
- Physical
- Cognitive
- Sensory
- Emotional/Behavioral
- Other
7.. Are you or your son/daughter receiving or waiting for services by the Regional Human Services District or Authority, Office for Citizens with Developmental Disabilities, or Office of Behavioral Health?*
- Yes
- No
a. If Yes, check all that apply to you or your child (receiving the service or on a waiting list to receive the service)*
- New Opportunities Waiver (NOW)
- Children's Choice (CC)
- Supports Waiver (SW)
- Residential Options Waiver (ROW)
- Individual / Family Support
- Flexible Family Fund
- EarlySteps
- I am not receiving nor on the waiting list for a service
b. If No, why have you or your son/daughter not been determined eligible for these services?*
- Yes
- No
- Not applicable
c. If you or your child has not applied for eligibility for any of these services, please explain why. If you have, please type n/a.*
8. Is your son/daughter receiving special education services?*
- Yes
- No
9. How does your disability or your child’s disability affect your daily life, his/her daily life or the daily life of your family?*
10. Please tell us a little about yourself and your family, including information on other natural supports who would provide care to your son/daughter while you are at Partners’ sessions.*
11. Please share your views on people with disabilities being fully included in their communities.*
12. Please list any activity, membership, and/or office held in advocacy organizations. (This is not a requirement for participation)*
13. Why do you want to participate in Partners in Policymaking and what do you hope to gain?*
14. Identify one or two specific disability related problems that are of particular interest to you. If you have any ideas to address these issues, please share.*
15. How did you learn about Partners in Policymaking?*
- Families Helping Families Center
- Newspaper
- Partners' Graduate
- EarlySteps
- OCDD Office
- Advocacy Group
- Facebook
- LaCAN
- DD Council
- Partners Graduate
- Individual
- Other
a. If Partners graduate, an Individual, or other please list below
16. Please list 2 references and their appropriate information below. You can add references by clicking the plus sign (+) beside the question.*
Name Phone Number Email Address
17. If anyone helped you prepare this application, please provide his or her name, address and phone numbers:
Name Address City State Zip Home Phone Cell Phone

APPLICATION CHECKLIST

Did you remember to do these things?

Complete ALL sections of the application?
Submit on or before the deadline of September 30th

Definition of Developmental Disabilities

Application for Participation

PIP Application

Demographics

COMPLETE ONLY FOR YOUR CHILD WITH A DEVELOPMENTAL DISABILITY:

APPLICATION CHECKLIST