KCDD Membership Application - 2024 Question Title * 1. Contact Information Full Name Title/Organizational Affiliation Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 2. I am applying to KCDD as a: 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) Question Title * 3. Please share any additional information about your background, role or experiences in the IDD community. Question Title * 4. Gender Female Male Other Question Title * 5. What is your race or ethnicity? 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: Question Title * 6. Can you share some additional background on your interests and passion for joining KCDD as a Council Member? Question Title * 7. Ideally, Council members are involved with many Council activities. How involved can you be with the Council? 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 Question Title * 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? 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 Question Title * 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? 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 Question Title * 10. Please list anything that you have done with community organizations or disability organizations, and your experience advocating for people with IDD. Question Title * 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) Done
