Maine Developmental Disabilities Council

Membership Application Form

  1. Click here for a printable Membership Application (PDF)

  2. Name(*)
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  3. Address Line 1(*)
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  4. Address Line 2
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  5. Primary Phone #(*)
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  7. Additional Phone #
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  9. Additional Phone # 2
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  11. Email(*)
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  12. Please check either "yes" or "no" for each of the following:

  13. A) Person with a developmental disability (DD)(*)
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  14. B) Parent/guardian of a child under 18 years old who has DD(*)
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  15. C) Immediate family/guardian of an adult who has DD(*)
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  16. D) 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(*)
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  17. E) Employed by a State agency that provides services for children and/or adults with developmental disabilities(*)
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  18. Please respond to each of the following questions.

  19. A) How did you hear about the Maine DD Council?(*)
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  20. B) Why do you want to be a member of the Maine DD Council?(*)
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  21. C) Please briefly describe your experiences related to services and/or supports for persons with developmental disabilities and their families(*)
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  22. 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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  23. 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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  24. (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.

  25. Reference 1 Name(*)
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  26. Reference 1 Primary Phone(*)
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  28. Reference 1 Email
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  29. Reference 1 How do you know this individual?(*)
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  30. Reference 2 Name(*)
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  31. Reference 2 Primary Phone(*)
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  32. Type
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  33. Reference 2 Email
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  34. Reference 2 How do you know this individual?(*)
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  36. 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.

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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