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Deadline: May 1, 2006
Disability Leadership Network of
Houston
2006/2007 Application
Thank you for your interest in participating in
the Disability Leadership Network of Houston training program. The dates and times of our 2006/2007 training
sessions will be:
September 8, 2006 (Friday,
9:30 a.m. 4:00 p.m.)
October
6, 2006
(Friday,
9:30 a.m. 4:00 p.m.)
November
3, 2006 (Friday,
9:30 a.m. 4:00 p.m.)
December
1, 2006 (Friday,
9:30 a.m. 4:00 p.m.)
January
27, 2007 (Saturday,
9:00 a.m. noon)
February
2, 2007 (Friday,
9:30 a.m. 4:00 p.m.)
March
2, 2007 (Friday,
9:30 a.m. 4:00 p.m.)
April
13, 2007 (Friday,
9:30 a.m. 4:00 p.m.)
All
sessions will be held at Emmanuel Episcopal Church, 15015 Memorial Drive,
Houston, 77079 (at the corner of Eldridge and Memorial in Northwest Houston). There is no cost to participants, and
supports or accommodations will be provided as needed.
Selected
participants will be expected to attend all 8 sessions and complete
homework assignments between sessions.
Please check your calendars before answering the following
questions. If you need more space,
you may attach additional sheets of paper. And if you have any questions or need assistance in filling
out the application, please call 713-303-9993.
Name:__________________________
County:____________________
Address:_____________________________________________________
City:____________________________ Zip
Code:__________________
Telephone: (Day)_________________
(Evening)__________________
Email:___________________________
Fax:______________________
Age:______________
Occupation:______________________________
Please check:
Female □ Male □
African
American □ Asian American □ Caucasian □ Hispanic □
Native
American □ Other □:______________________________
A. Do you have a developmental disability
(see definition on back page) or
traumatic brain
injury? Yes □ No □
If yes:
What
is your disability?________________________________
Age
of onset?_____________
Do
you live: In
your own home? □ With parents? □
In a group home? □ Other?___________________
B. Are you the parent or legal guardian of
a child with a developmental
disability (see
definition on back page)?
Yes □ No □ If
yes:
Name of child with disability:___________________ Age:________
Type
of disability:_________________________________________
Does
the child live at home?
Yes □ No □
If no, child lives: _____________________________________
Do
you have other children?
Yes □ No □ Ages?____________
Childıs
school district:______________________________________
C. Do you work professionally on behalf of
children or adults with
disabilities?
Yes □ No □ If yes, please describe your role in
the
disability
community: ______________________________________
_________________________________________________________
_________________________________________________________
D. In what areas does disability affect
your ability, your childıs ability, or the
ability of the
people you work with to function?
(Please check all that
apply):
Self-care
□ Mobility □
Receptive Language □ Self-Direction
□
Expressive
Language □ Capacity for Independent Living □
Learning □ Economic Self-Sufficiency □
E. Please tell us about yourself:
F. What motivates you to apply for this
program? What skills or knowledge
do you hope to
gain from the program?
G. Why are you a good candidate for the
Disability Leadership Network of
Houston
program?
H. What types of experiences (if any) have
you had in advocating for
people with
disabilities?
I. Please list any memberships in
disability or advocacy organizations and
indicate any offices
held (not required to apply):
J. Please describe any supports or
accommodations that you will need to
be able to
successfully participate in the program:
K. How did you learn about Disability
Leadership Network of Houston?
M. Please list 2 references, including
name, address and phone number:
(Letters of
recommendation are welcome but not required, and limited
to two.)
1. _______________________ 2.
________________________
_______________________
________________________
_______________________
________________________
_______________________
________________________
By submitting this application, I understand that,
if selected, I am committing to attend all 8 training sessions and complete any
homework assignments. I understand
that failure to meet these commitments may prevent me from graduating from the
program. I also understand that
this application does not guarantee my selection for this yearıs class or
future classes.
____________________________________
_________________
Signature Date
13150 FM 529, Suite 106
Houston, TX 77041
Application deadline is May 1,
2006.
CONFIDENTIALITY
STATEMENT
The information provided in this application will
be kept strictly confidential and will be used solely for the purpose of
participant selection in the Disability Leadership Network of Houston program.
Developmental Disability
Definition
The term ''developmental disability'' means a severe, chronic
disability of an individual that -
(A) is
attributable to a mental or physical impairment or combination of mental and
physical impairments;
(B) is
manifested before the individual attains age 22;
(C) is
likely to continue indefinitely;
(D) results in substantial functional limitations in 3 or more
of the following areas of major life activity:
(i) Self-care
(v)
Self-direction
(ii) Receptive and expressive
language (vi) Capacity for independent
living
(iii) Learning (vii) Economic
self-sufficiency
(iv) Mobility
(E) 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.
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.
Disability Leadership Network of Houston is a project
of Family to Family Network, funded through a grant from the Texas Council for
Developmental Disabilities (TCDD) with funds provided by the U.S. Department of
Health and Human Services,
Administration on Children and Families,
Administration on Developmental Disabilities.