2020 Leadership Development Program for the Deaf & Hard of Hearing Thursday, June 18th at 1:00 PM to Sunday, June 21st at 12:00 PM Applications have to be postmarked by March 1, 2020. ONLY COMPLETE APPLICATIONS WILL BE CONSIDERED (Application and References) Name: (First) ____________________ (M.I.) _______ (Last) _____________________________ Gender: _____ Birth Date _________________ Race (Optional) ________________ T-Shirt Size__________ Email Address _______________________________ Mailing Address ________________________________________ City ___________________ Zip ___________ County ________________ Phone _____________________ Current Grade ________ Expected Graduation Date ___________ High School ________________________ School Phone__________________________ Parent / Guardian ________________________________ Phone _________________________ Parent Email _____________________________________ Please check the ones that apply: How did you learn about the Program? School Friend Internet/Email/Social Media Transition Event Other_______________ I am a Vocational Rehabilitation (VR) Client Yes No Don't Know I am a DMH Regional Office client Yes No Don't Know Have you participated at your local Center for Independent Living (CIL)? Yes No Don't Know Please check ALL that apply: Deaf / Hard of Hearing: * I use sign language * I use assistive listening devices * I use real time captioning * I use lip reading * I need interpreter services * I use note takers * Certified Deaf Interpreter (CDI) Please specify any additional details_________________________________ Blind / Visually Impaired: * I read with Braille * I read with large print * I need assistance with mobility * I prefer electronic format Mobility Disability (e.g. spinal cord injury, muscular dystrophy, other): * I use a wheelchair / scooter * I cannot walk upstairs * I use a walker, cane, or crutches * I cannot walk long distances Immune Disability: * Crohn's Disease * Rheumatoid Arthritis * Sickle Cell Anemia * Other __________________ * Autism * Asperger's syndrome * Traumatic Brain Injury * Down Syndrome * Intellectual Disability * Mental Health Disability (e.g. anxiety, depression, bipolar/mood disorder, obsessive compulsive disorder, other) * Neuro/Muscular Disability * Learning Disability (e.g. dyslexia, dyscalculia, ADD/ADHD, other...) ___Reading ___Math ____Written * Multiple Disabilities * Chronic Illness (e.g. cancer, cystic fibrosis, diabetes, heart disease, other) * Chemical / Environmental Sensitivity * Other (describe) _______________________________ Please list all accommodations needed to participate (interpreter, personal care attendant, special diet, etc.) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 1. What organizations or activities are you involved in with your school and/or community? This may include any offices you held, club memberships, after school activities, work experience, church activities, community volunteer, etc. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. List 3 goals that you have for your future. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. List 3 leadership strengths that you possess. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 4. References Please list three references that we may contact by phone. One reference must be a high school principal, counselor, or a teacher. The other references may be any adult who knows you well, other than a parent or relative, for example, scout leader, employer, coach, community leader, etc. At least one reference must be from outside the school. 1. Name (School) ______________________________ Phone____________________ 2. Name _______________________________ Phone ____________________ 3. Name _______________________________ Phone ____________________ ONLY COMPLETE APPLICATIONS WILL BE CONSIDERED. *Application is completed. *3 References with good contact numbers are given *Must be submitted online or postmarked by March 1, 2020. References will be contacted by phone between Mid-March and beginning of April. Please make sure they are aware about being a reference and that their contact information is correct and updated if necessary. Application may be submitted online. If unable to submit online you may email, fax, or mail your documents to: Governor's Council on Disability Leadership Development Program (LDPDHH) PO Box 1668 Jefferson City, MO 65102 rachel.rackers@oa.mo.gov http://disability.mo.gov Phone: 800-877-8249 Fax: 573-526-4109