2018-2019 Eastern Shore LEADers Application

Families can expect to hear from us about their acceptance by November 30, 2018.

Complete this application only if you are able to attend ALL training sessions.

Training dates are:
January 26
February 16

March 9
April 6

May 4

May 18

June 1 (snow date)
June 8 (snow date)

All training times are from 9am to 4pm and will be held at Chesapeake College (1000 College Circle, Wye Mills, MD 21679) in HEC 110.

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* 1. Please provide your contact information.

First Name: *

Last Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *

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* 2. Are you able to attend ALL six training dates?

Yes

Comment

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* 3. What county do you live in the Eastern Shore?

Other (please specify)

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* 4. Are you Hispanic?

Yes

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* 5. What is your race?

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

From multiple races

Other (please specify)

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* 6. Please tell us about your child(ren) with a disability.

	Age	Disability	Race	Hispanic?
Child 1	Child 1 Age menu	Child 1 Disability menu	Child 1 Race menu	Child 1 Hispanic? menu
Child 2	Child 2 Age menu	Child 2 Disability menu	Child 2 Race menu	Child 2 Hispanic? menu
Child 3	Child 3 Age menu	Child 3 Disability menu	Child 3 Race menu	Child 3 Hispanic? menu
Child 4	Child 4 Age menu	Child 4 Disability menu	Child 4 Race menu	Child 4 Hispanic? menu

Other (please specify)

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* 7. Describe any challenges you and your family have faced in receiving appropriate educational services for your children.

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* 8. I understand that, if chosen as a participant, that I will be required to participate in at least 5 leadership activities which could include involvement in the local Special Education Advisory Committee, PTA, other committees or advisory boards, legislative or policy advocacy or other activities)

Yes

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* 9. List any parent or advocacy training, volunteer activities and groups you are involved in.

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* 10. Tell us your concerns for children with disabilities in your community?

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* 11. Tell us why you should be chosen for The Eastern Shore Maryland LEADers Program. (Include your interests and skills that will help you be a champion for children and youth with disabilities)

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* 12. How will you use what you learn to advocate for children and youth with disabilities in the Eastern Shore?

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* 13. Provide two (2) references who know of your work on behalf of children with disabilities. The references may not be family members. Please list name, email address, and phone number for each reference.

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* 14. Do you need a sign language interpreter?

Yes

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* 15. Do you have any other language needs (i.e. French, Chinese, Mandarin, Large Print, etc.)?

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* 16. ACCOMMODATIONS: Please tell us any accommodations that you require (including dietary). Please note that we will try to make reasonable accommodations but you may need to consider bringing food you are confident will meet your needs.