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KCDD Council Member Application
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1.
Contact Information
(Required.)
Full Name
Title/Organizational Affiliation
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Country
Email Address
Phone Number
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2.
I am applying to KCDD as a:
(Required.)
Self-Advocate in Kansas
Parent/guardian of a child (under 18 years old) who has an IDD in Kansas
Immediate family/guardian of an adult who has an IDD in Kansas
Member or employee of a local and/or non-governmental agency, or a nonprofit organization with a mission focused on serving the IDD community in Kansas
Employed by a Kansas State Agency that provides services for children and/or adults with IDD
Other (please specify)
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3.
Please share any additional information about your background, role or experiences in the IDD community.
(Required.)
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4.
Gender
(Required.)
Female
Male
Other
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5.
What is your race or ethnicity?
(Required.)
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Multiracial or Multiethnic
Native American or Alaska Native
Native Hawaiian or other Pacific Islander
White
Another race or ethnicity, please describe below
Self-describe below:
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6.
Can you share some additional background on your interests and passion for joining KCDD as a Council Member?
(Required.)
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7.
Ideally, Council members are involved with many Council activities. How involved can you be with the Council?
(Required.)
Very involved - I can participate in many activities beyond the four quarterly meetings per year
Somewhat involved - I am available for KCDD meetings but my time outside of meetings is limited
A little Involved – I can only participate in four KCDD meetings per year
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8.
Council members help represent the IDD community at public meetings, conferences and educational forums. How comfortable are you with speaking in front of groups?
(Required.)
Very Comfortable - I like working in groups and have made presentations to groups
Comfortable - I like working in groups but prefer to have someone help me make presentations
Uncomfortable - I like working in groups but not giving presentations
Very Uncomfortable – I don’t like working in groups
Not Currently Comfortable but wIlling to do with training and support
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9.
As a Council member, you may be asked to call, write or meet with Kansas State Senators and Representatives or give testimony at our Kansas Capitol in Topeka, Kansas. You will receive training to do this and can work with another Council member or Council staff.
How comfortable are you with doing this?
(Required.)
Very Comfortable -- I have met with my legislators and presented my views
Comfortable -- I can do this with enough support, information, and a good partner
Uncomfortable – I have no experience doing this
Very Uncomfortable – I don’t want to do this
Not Currently Comfortable but wIlling to do with training and support
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10.
Please list anything that you have done with community organizations or disability organizations, and your experience advocating for people with IDD.
(Required.)
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11.
References: Provide two references that KCDD can contact for a recommendation. These should be individuals who know you personally and/or professionally and would be able to comment on the strengths, skills and experience you would contribute as a member of the Council.
(Please include full names, titles/affiliations, direct phone numbers and email addresses for two references)
(Required.)
