Leaders in Policy Advocacy (LIPA) Training Application

Leaders in Policy Advocacy (LIPA) is an intensive, innovative training program for adults with developmental disabilities and parents of children with developmental disabilities. Participants will be trained and supported to become leaders in the disability rights movement.

Participation in LIPA requires a significant time commitment. Six (6) weekend sessions begin on Fridays at 12:30 pm and end for the day at 9:00 p.m. The class resumes at 8:30 a.m. on Saturdays and concludes at 3:00 p.m. There is no cost to participate in the training. Participants will be asked to share a hotel room with another class member, if lodging is needed. Meals will be provided, including to caregivers, and participants will be reimbursed for mileage to and from the training sessions. Attendance is required at each weekend session. Please apply ONLY if you can make the commitment.

If you need assistance completing this application, please contact Salli Christenson at The Arc Michigan, 800-292-7851 x 130 or salli.c@arcmi.org

NEXT CALL TO BE HELD IN WAYNE COUNTY

APRIL - SEPTEMBER 2017

VENUE AND DATES TO BE ANNOUNCED SOON!

Name: *

Address: *

City: *

County: *

Zip Code: *

Phone: *

Ethnicity (optional):

Age:

Email: *

Emergency Contact Name: *

Relationship: *

Phone Number: *

1. Are you a person with a disability? (if no, proceed to Question 2) *

Yes

No

If yes, please specify your disability and provide information about how it affects your daily life:

What kinds of supports, services or assistive technology services/devices do you use or do you receive?

2. Are you a parent of a child with a developmental disability? *

Yes

No

If so, what services does your family or your son/daughter receive?

How old is your child?

Please specify by child his/her disability and provide information about how it affects his/her daily life and that of your family.

Please provide some specific information on how this diagnosis or disability affects your access to needed services.

Is your son/daughter receiving special education services?

Yes

No

Not Applicable

If yes, describe those services

3. Do you, or does your son/daughter, meet the federal definition of a person with a developmental disability? * 🛈

Yes

No

4. Identify one or two specific problems or issues related to disability that are of greatest concern to you.

5. If you have a disability, what accommodations do you need to help you actively participate in the weekend sessions (such as wheelchair access or larger print)?

6. Do you need interpreter services? * 🛈

Yes

No

If yes, please specify:

7. If you are a parent, will you be using respite/child care services, so you can participate in the Leaders in Policy Advocacy Program?

Yes

No

PLEASE NOTE: No child care will be provided onsite. However, some reimbursement for the costs of child care may be provided if no other source of funds is available to you.

8. If you are a person with a disability, will you be using personal care attendant services during the weekend sessions?

Yes

No

PLEASE NOTE: Some reimbursement for the costs of personal care attendat services may be provided if no other source of funds is available to you.

9. Please tell us about yourself/your family.

If you are working, tell us about your job and the kind of work you do:

Are you currently a member of, do volunteer work for, or are involved with an advocacy organization?

Yes

No

If yes, what is the name of the organization(s) and what role(s) do you play?

If you're in school, tell us about your field of study or the types of classes you are taking:

In what type of community/volunteer activities are you involved?

What are some of your personal interests?

Please share any life experiences that have been special joys or challenges for you, your child or your family:

10. Tell us why you want to participate in the Leaders in Policy Advocacy program.

11. How did you learn about the Leaders in Policy Advocacy Program?

Please submit completed application by regular mail, fax, or email, to:

Salli Christenson at The Arc Michigan

1325 S. Washington Ave, Lansing, MI. 48910

Fax (517) 487-0303

salli.c@arcmi.org

LEADERS APPLICATION