Partners in Leadership Application

Applicant Information

First Name *

Last Name *

Address

Street Address

City

State

Country

Zip Code

Phone (Day) *

Phone (Evening) *

Email *

Date Of Birth

Are you a member of an Arizona tribe? *

Yes

Which Arizona tribe are you a member of?

How long have you lived in Arizona?

Do you currently work for a state agency, disability organization, or provider company?

Yes

Applicant Background

Please select the option(s) that best describe you and provide additional details where applicable.

Individual with a disability

Parent or guardian of an individual with a disability

Family member (other than a parent) of an individual with a disability

Please specify your disability

Age

Are you your own legal guardian?

Yes

Child’s age

Please specify your child's disability

Do you also identify as a person with a disability?

Yes

Please specify your disability

Family member’s age

Please specify your family member's disability

Application Questions

Please answer the following questions. If additional space is needed, you may attach additional pages.

What specific issue, concern, or experience encouraged you to apply for Partners in Leadership? *

Please describe how disability affects your life, either personally or through a family member. *

What services or supports are currently part of your or your family member’s life? *

Please list any involvement in community organizations, civic groups, or advocacy activities.

What impact would you like to make in your community? How do you see yourself using what you learn in Partners in Leadership? *

Is there anything else you would like us to know about you?

Please share how you heard about Partners in Leadership

References

Please provide two references who are not related to you and who are familiar with your interest in disability advocacy or community leadership.

You are responsible to send each of your references the following link and ask them to complete a brief recommendation questionnaire. [Insert Link]

Reference 1

Reference 1 Name *

Reference 1 Phone *

Reference 1 Email *

Reference 2

Reference 2 Name *

Reference 2 Phone *

Reference 2 Email *

Accommodations

Raising Voices Coalition is committed to ensuring that all participants can fully participate in the Partners in Leadership program. Please let us know if you require any accommodations to support your participation.

Accessibility and Communication Needs

Please check any accommodations that would be helpful:

Wheelchair accessible space

Large print materials (please specify preferred font size)

Seating near the front of the room

Language translation or interpretation services (please specify language)

Use of an AAC (Augmentative and Alternative Communication) device

Large print material size preference

What language do you need for translation or interpretation accommodations?

Additional Accommodation Requests

Please list any other accommodations that would support your participation in the program:

Support Needs

Do you currently have a personal care assistant for daily living needs? *

Yes

Will a direct care worker be accompanying you during program sessions? Please note that participants are responsible for arranging and covering the cost of any support staff, as the program does not provide direct care services. *

Yes

Are you deaf or hard of hearing? *

Yes

Meal & Allergy Information

Do you have any dietary restrictions? *

Yes

Please list any food allergies or medically necessary dietary restrictions below. We will make reasonable efforts to accommodate allergy related needs.

While we will do our best to consider other dietary preferences, accommodations for non medical or preference based requests are not guaranteed.

Lodging

Participants will be provided lodging at the designated training location for each session. Participants are expected to stay overnight from Friday to Saturday. Accommodations will include a shared hotel room with another participant of the same gender, with each individual having their own bed.

Rooms are reserved for program participants only.

Accessible room requested? *

Yes

Roll-in shower requested?

Yes

Personal Commitment

Partners in Leadership requires a significant commitment of time and engagement. Participants are expected to attend all eight two day weekend training sessions and actively participate in program activities.

Participants are also expected to stay overnight at the designated hotel from Friday to Saturday for each session, as this is an important part of the program experience and cohort engagement.

Please review the following commitments:

I am committed to attending all eight training sessions. *

Yes

I understand that attendance at all sessions is required. *

Yes

I agree to complete brief assignments between sessions. *

Yes

I agree to complete program evaluations and follow-up surveys. *

Yes

Applicant Signature *

Clear

Applicant Signature Date *

Language help is available at no cost to you. Email Raising Voices Coalition at 520-980-9806 to ask for this material in other formats.

La ayuda en otros idiomas está disponible sin costo alguno para usted. Envíe un correo electrónico a Raising Voices Coalition a 520-980-9806 para solicitar este material en otros formatos.

About Partners in Leadership

Partners in Leadership is administered by Raising Voices Coalition through a contract with the Arizona Department of Economic Security Division of Developmental Disabilities (DDD).

The program is based on the original leadership model developed in Minnesota and is designed to strengthen leadership, advocacy, and civic engagement within Arizona’s disability community.

Non-Discrimination Statement

Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI and VII) and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, Raising Voices Coalition prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, and disability. Raising Voices Coalition must make a reasonable accommodation to allow a person with a disability to take part in a program, service, or activity. Auxiliary aids and services are available upon request to individuals with disabilities.

For example, this means that, if necessary, Raising Voices Coalition must provide sign language interpreters for people who are deaf, a wheelchair-accessible location, or enlarged-print materials. It also means that Raising Voices Coalition will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance, if at all possible.

To request this document in an alternative format or for further information about this policy, please contact Raising Voices Coalition at [email protected]. To obtain this document in another format or to get additional information about this policy, please contact the Raising Voices Coalition at [email protected].

Partners in Leadership

Thank you for your interest in Partners in Leadership, a statewide leadership and advocacy training program designed for individuals with disabilities and parents or caregivers raising children with disabilities or special health care needs.

Partners in Leadership prepares participants to become community leaders and effective advocates by building knowledge about disability policy, systems, and civic engagement.

Selected participants will join a cohort of leaders committed to strengthening disability policy, services, and community inclusion across Arizona.