ONLY COMPLETE APPLICATIONS WILL BE CONSIDERED (Application and References) **All locations are postponed until spring 2021** Applications have to be submitted or postmarked by January 31, 2021 Which Regional Leadership Forum would you like to attend? (Choose ONE) Jefferson City on March 13th Cape Girardeau on March 20th Kansas City on April 10th Springfield on April 17th 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 Forum? School Friend Internet/E-mail/Social Media Transition Event 0 Other I am a Vocational Rehabilitation (VR) or Rehabilitation Services for the Blind (RSB) 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 describe your disability – (This will assist in assuring that we include students with diverse disabilities) Primary Disability (medical diagnosis): Onset of Disability (age): 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 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, special diet, etc.) Short answer and Essay: Complete the following questions. If you are using a scribe to complete this portion of the application, please make sure responses are written reflecting your voice. If you have questions or need assistance with completing this application please contact Rachel at 573-526-4564 or rachel.rackers@oa.mo.gov. 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 If unable to submit online you may email, fax, or mail your documents to: Governor’s Council on Disability Missouri Youth Leadership Forum PO Box 1668 Jefferson City, MO 65102 rachel.rackers@oa.mo.gov http://disability.mo.gov Phone: 800-877-8249 Fax: 573-526-4109