MARYLAND DEVELOPMENTAL DISABILITIES COUNCIL
MEMBERSHIP APPLICATION
217 E. Redwood St., Suite 1300
Baltimore, MD 21202
800-305-6441
410-767-3670

We will provide accommodations requested so that members may fully participate on the Council.  If you would like this application in an alternative format or would like to apply over the telephone, please contact Linda at (410) 767-6249 or (800) 305-6441, ext 1.

Mail Application to above address or click submit at the bottom of this form.
This application can also be faxed to 410-333-3686
Please add pages as necessary.

Name

Address

City   State   Zip

County Allegany Anne Arundel Baltimore County Calvert Caroline Carroll Cecil Charles Dorchester Frederick Garrett Harford Howard Kent Montgomery Prince George's Queen Anne's St. Mary's Somerset Talbot Washington Wicomico Worcester Baltimore City (select one)

Home Phone     Work Phone

Fax Email Address

1. Representation:

Person With a Developmental Disability
A Parent/Relative Of A Child With a Developmental Disability
A Parent/Relative Of An Adult With a Developmental Disability
A Person with a Developmental Disability Who is or was in an Institution
A Relative, Parent, or Guardian of a Person with a Developmental Disability Who is or

was in an Institution

A Service Provider or Employee of a Service Provider
State Agency Representative
Other (please list)

2. IF YOU ARE A PERSON WITH A DEVELOPMENTAL DISABILITY, PLEASE TELL US ABOUT YOURSELF.

3. IF YOU ARE A PARENT OF A CHILD/CHILDREN WITH DEVELOPMENTAL DISABILITIES PLEASE TELL US ABOUT YOURSELF AND YOUR CHILDREN, INCLUDING THEIR AGES:

4. IF YOU ARE REPRESENTING AN AGENCY/ORGANIZATION, PLEASE STATE THE NAME OF THE ORGANIZATION OR AGENCY YOU ARE REPRESENTING, ITS MISSION, AND YOUR POSITION: 

5. WHY DO YOU WANT TO BE ON THE COUNCIL?  WHAT ARE YOUR SPECIFIC INTERESTS?

6. WHAT STRENGTHS DO YOU BRING TO THE COUNCIL? 

7. BEING A COUNCIL MEMBER IS A COMMITMENT.  YOU NEED TO ATTEND QUARTERLY COUNCIL MEETINGS AND SERVE ON A COMMITTEE THAT MEETS 4-6 TIMES PER YEAR.  IT IS VERY IMPORTANT THAT AS MANY COUNCIL MEMBERS AS POSSIBLE ATTEND THESE MEETINGS.  DO YOU BELIEVE YOU WILL BE ABLE TO MAKE THIS SORT OF COMMITMENT TO THE COUNCIL?  PLEASE BRIEFLY EXPLAIN.

8. PLEASE TELL US ABOUT ANY COMMUNITY ORGANIZATIONS OR DISABILITY ORGANIZATIONS YOU ARE INVOLVED WITH OR ABOUT ANY EXPERIENCE YOU HAVE OR HAVE HAD IN ADVOCATING FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES (Membership in other organizations is NOT a requirement).

9. HOW DID YOU LEARN ABOUT THE MARYLAND DEVELOPMENTAL DISABILITIES COUNCIL? 

10. PLEASE LIST THREE (3) NON-FAMILY REFERENCES WITH ADDRESSES AND PHONE NUMBERS.  AT LEAST TWO OF THESE REFERENCES SHOULD BE DIRECTLY RELATED TO DEVELOPMENTAL DISABILITIES AND YOUR POTENTIAL COUNCIL MEMBERSHIP.

T H A N K   Y O U   F O R   Y O U R  
I N T E R E S T   I N   T H E   C O U N C I L!