Membership Application Form - Maine Developmental Disabilities Council

Application for Membership

Click here for a printable Application for Membership (PDF)

We strongly encourage you to answer all questions honestly and to the best of your abilities. This is your 1^st chance at making a good impression and leaving questions blank delays the review of your application.

Name(*)

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Today's Date

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Address (*)

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City, State, Zip Code(*)

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Home Phone(*)

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Work Phone

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Cell Phone

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Email(*)

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Do you live in Maine?(*)

Do you live in Maine?

Yes, Full Time

Yes, Part Time

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(*You must be a resident of Maine to serve on the Maine Developmental Disabilities Council.)

Please check either "yes" or "no" for each of the following:

I am a:

Person with a developmental disability (DD)(*)

Person with a developmental disability (DD)YesNo

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If yes, do you now or have you ever lived in an institution (such as Pineland or a nursing home)?

If yes, do you now or have you ever lived in an institution (such as Pineland or a nursing home)?YesNo

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Parent/guardian of a child under 18 years old who has DD(*)

Parent/guardian of a child under 18 years old who has DDYesNo

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Immediate family/guardian of an adult who has DD(*)

Immediate family/guardian of an adult who has DDYesNo

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If yes, is the adult who has DD unable to advocate for himself/herself, even with support?***

If yes, is the adult who has DD unable to advocate for himself/herself, even with support?***YesNo

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If yes, has the adult with DD ever lived in an institution (e.g. Pineland Center or a nursing home)?

If yes, has the adult with DD ever lived in an institution (e.g. Pineland Center or a nursing home)?YesNo

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Member or employee of a local and/or non-governmental agency, or a non-profit group concerned with services for persons with DD and their families in Maine(*)

Member or employee of a local and/or non-governmental agency, or a non-profit group concerned with services for persons with DD and their families in MaineYesNo

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Employed by a State agency that provides services for children and/or adults with developmental disabilities(*)

Employed by a State agency that provides services for children and/or adults with developmental disabilitiesYesNo

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PLEASE READ BEFORE CONTINUING WITH YOUR APPLICATION!

**The Federal definition of ‘developmental disability’:

Is attributable to a mental or physical impairment or combination of mental and physical impairments
Is manifested before the individual attains the age of 22
Is likely to continue indefinitely
Results in substantial functional limitations in 3 or more of the following areas of major life activity: self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; and economic self-sufficiency
Reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated.

An individual from birth to age 9, who has a substantial developmental delay or specific congenital or acquired condition, may be considered to have a developmental disability without meeting 3 or more of the criteria described above if the individual, without services and supports, has a high probability of meeting those criteria later in life.“ (Developmental Disabilities Assistance and Bill of Rights Act of 2000)

The federal definition is functional; it is intended to describe the nature and scope of limitations without reference to medical diagnosis

***Please note that an immediate relative or guardian of an adult with a developmental disability may only be considered for Council membership if that adult is unable to advocate for himself/herself, even with supports.

A DD Council member is a public official.

How do we know?

A Public official is a member of a governing body. o The DD Council
A Public Official is often appointed by an elected member of the government.
- The Governor appoints the members (in the District of Columbia, it is the mayor)
A Public Official makes decisions about using public money to impact members of the public to fulfill functions of a program funded with public member.
- The Council receives federal funds to implement the 5-year plan
- The 5-year plan impacts people with intellectual and developmental disbilities in the State or Terriory.

General expectations of a Public Official

In general, public officials (Council members) should:

Uphold the highest ethical standards
- Follow your State or Territory ethics policies, and the Council Code of Ethics, (if that applies).
Put the interests of the public and the mission of the Council before your own personal interests
- Council members qualify for membership because of their lived experiences and/or professional and agency connection.
- Once selected, the member works for the good of the State or Territory through the Council 5-year plan.
- Maintain and enhance the public’s trust and confidence in the Council.
  - Do what you say you will do, be consistent, uphold the values of the Council.

Please respond to any/all of the following that apply to you.

1) If you are a Person with a Developmental Disability: please tell us a little about yourself and your disability.

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2) If you are the Parent, Guardian or Family member of a person with developmental disabilities: please tell us about your family member/ward with a developmental disability, including his/her relationship to you, disability, and age. If the person is over 18 years of age, please explain why he or she is unable to advocate for his/her self even if provided with support.

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3) If you are a Representative of an Organization or Agency: please tell us about your organization or agency, including its mission and your professional position.

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Please respond to each of the following questions.

A) How did you hear about the Maine DD Council?(*)

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B) Why do you want to be a member of the Maine DD Council?(*)

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C) Please briefly describe your experiences related to services and/or supports for persons with developmental disabilities and their families(*)

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D) What strengths and/or skills will you bring to the Council? (Examples: strong self-advocate, advocacy experience, experience with strategic planning, management, or communications, knowledge of the legislative process, personal commitment, etc.)(*)

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E) Will you be able to make the necessary time commitment involved in being a member of the Maine DD Council? Please briefly explain(*)

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(Please Note: The full Council meets bi-monthly (6 times) throughout the year. In addition, members are required to serve on at least one committee, which may meet as frequently as once a month. Members are expected to review materials and information sent by Council staff in preparation for meetings.)

References

Please provide two references we 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.

Reference 1

Name(*)

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Phone(*)

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How do you know this individual?(*)

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Reference 2

Name(*)

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Phone(*)

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How do you know this individual?(*)

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Please feel free to contact the Council at 207-480-1478 or toll free 833-713-2618 if you have questions or would like additional information.

Quick Links

DD Health Project
Self Direction Options
Get Involved
Upcoming Events
Project CONNECT
Support Broker Information
Guide for Services

Contact Us

Maine Developmental Disabilities Council
526 Western Avenue Unit 2
Augusta, ME 04330

Mail: 139 State House Station Augusta, ME 04333

Phone: 207-480-1478 or toll free 833-713-2618

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The website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $527,570.00 with 100% funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.