Project Leadership

          Name:
  Address where you receive mail.
        Street:
          City:
         State:
       Country:
      ZIP Code:

What type of community do you live in? Rural  Urban 

Daytime Telephone Number:
Evening Telephone Number:
Email:

Your Age: 18-25 26-35 36-45 46-55 55+

Race/Ethnic Identification:
Asian African American Caucasian/white
Hispanic Native American Other

Please choose one: Self-advocate Family Member

Do you or a family member have a developmental disability? Yes No

What is the developmental disability? Please read the cover sheet with the definition of Developmental Disabilities very carefully.

0. When did your disability or your family members occur?
Before age 22 After age 22

1. How does your disability affect you or your family member?
I or my family members has lived in an institution.
I or my family member lived or lives in a group home.
I or my family member needs support to live in a family home or in a home of my home.
I or my family member work in a sheltered workshop.
I or my family member receive supported employment services.
I do not have a job.
I or my family member receive Social Security benefits.
I or my family member have a history of being labeled mentally retarded.
Other. (explain below)

What does self determination mean to you?

List leadership accomplishment and/or activities you have been involved in at a local, state or national level. (Examples might include serving as an officer or board member of a local, state or national self advocacy group; being involved with state planning groups through your Developmental Disability Council or your state office of mental retardation and/or developmental disabilities; membership in other civic groups such as Kiwanis, Civitan, League of Women Voters etc.)

List examples of advocacy activities or accomplishments. (Examples might be organizing local and state self advocacy groups; organizing a rally in support of closing an institution; making presentations on self advocacy; speaking with your state, local or federal legislators; participating in a lawsuit; advocating for yourself or others to get an apartment, home, or job, etc.)

What are your future leadership goals? (Examples might be being an officer in a self advocacy or family organization ; serving on a board of directors - making a presentation and giving testimony ; running for a state or local government office, etc.)

What do you think about community participation by people with disabilities? Please discuss.

Have you completed any local or state leadership training programs? Please list your experience with leadership training. (Examples might be Board training provided by self-advocacy group or community organization; Partners in Policy Making; legislative advocacy training from a disability organization; or other training or leadership institutes.)

Are you willing to promote teamwork between family members and self advocates?
 Yes  No 

Can you come to Washington, D.C. for two (2) week-long training sessions?
 Yes  No 

Please attach three letters of reference in support of your application. These should be from leaders in the advocacy movement who can tell us about your leadership potential. A letter from your state’s Developmental Disability Council , University Affiliated Program, or Protection and Advocacy agency is recommended. You may also add any other information that you think would help us know who you are.

To process this form while online press the "Submit form" button below or return the completed application electronically to Sally.Weiss@comop.org; fax it to (202) 721-0124; or mail it to: Community Options, Inc., 1130 17th Street NW, Suite 430, Washington, DC 20036. Application deadline is December 15, 2000.