Apply for Partners in Policymaking Program

Partners in Policymaking is an initiative of the Louisiana Developmental Disabilities Council (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 is for people with developmental disabilities and for parents of young children with developmental disabilities. The goal is to help people learn how to speak up for themselves and make positive changes in their communities. People in this program attend six workshops. Each workshop lasts two days and takes place between January and June. During these workshops, participants learn advocacy and leadership skills. Filling out this application and taking part in the program takes time, energy, and commitment. Please be sure you can attend all six workshops before applying.

For questions or more information about Partners in Policymaking please contact:
Rebecca Fruge, Partners In Policymaking Coordinator, at [email protected]

Option 1: Mail or E-mail

Download the Microsoft Word version of the form here, fill out and print.

Mail to the address below:
Louisiana Developmental Disabilities Council
Attn: Partners in PolicymakingP.O. Box 14148
Baton Rouge, LA 70898

Option 2: Electronic Submission

Fill out the form below and submit your information electronically.

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This field is for validation purposes and should be left unchanged.
Attendance is required at each weekend session. All sessions are held in Baton Rouge. Will you make a time commitment of two days (three days in January), one weekend a month (January through June), for six months?*
- Yes
- No
PIP Application
Name*
First Last
Address*
Street Address Address Line 2 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 you or 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?
c. If you or your child has not applied for eligibility for any of these services, please explain why.
8. Is your son/daughter receiving special education services?*
- Yes
- No
a. If Yes, please describe.
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
- EarlySteps
- OCDD Office
- Advocacy Group
- Facebook
- LaCAN
- DD Council
- Partners Graduate
- Individual
- Newspaper
- 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
*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.
Please review the federal definition of Developmental Disabilities below.*
(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: (I) Self-care. (II) Receptive and expressive language. (III) Learning (IV) Mobility (V) Self-direction (VI) Capacity for independent living (VII) 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. I certify that I have read the definition of developmental disabilities and understand that this must apply to me and/or my child in order to be considered for the Partners in Policymaking program.
Electronic Signature
By entering your name and date below, you signify that the above information is true and correct to the best of your knowledge.
Name/Signature*
Signature Date*

Name	Age	Disability/Diagnosis	Gender	Age at onset of disability	Does your child live at home with you?	If not, where?

Name	Phone Number	Email Address

Name	Address	City	State	Zip	Home Phone	Cell Phone

Option 1: Mail or E-mail

Option 2: Electronic Submission

PIP Application

Demographics

COMPLETE ONLY FOR YOUR CHILD WITH A DEVELOPMENTAL DISABILITY:

*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.

Electronic Signature