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Membership Application

Name *

First

Last

Email *

Phone 1 *

Phone 2

Address *

Address Line 1

Address Line 2

City

State

Zip Code

I am: *

Male
Female
Nonbinary (neither, both, or something else)

I am: *

White/Caucasian
Black/African American
Hispanic/Latino
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaskan Native
I don’t know my race/choose not to tell you my race

I am a: *

Person with a developmental disability
Parent or guardian of a child with a developmental disability
Third Choice
Family member or guardian of an adult with a developmental disability*
Person with a developmental disability who is or was in an institution
Family member or guardian of a person with a developmental disability who is or was in an institution*
Employee of a developmental disabilities service provider.
Employee of a community organization.
Other:

* Family members of adults can only be considered for membership if the person with a developmental disability is unable to advocate for themselves.

If you are an employee of a developmental disabilities service provider or community organization, please enter the organiation name below. *

If you are a person with a developmental disability, please tell us about yourself. *

If you are a parent or guardian of a person with developmental disabilities, please tell us about yourself and your family member with a developmental disability, including their age. *

If you are representing an organization, what does the organization do and what is your position? *

Why do you want to be on the Council? What issues are you interested in? *

What strengths do you bring to the Council? *

Council members attend 4 Council meetings each year. They also serve on at least 1 committee or work team that meets 2-4 times each year. If you join the Council, could you meet this requirement? *

Please tell us about community organizations or disability organizations you are involved with. Please also tell us about experience you have advocating for people with developmental disabilities (Membership in other organizations is NOT a requirement). *

How did you learn about the Council? *

Please list 3 references with phone numbers. They should be people who can talk about why you would make a good Council member. They should not be your family members. *

Comment or Message

217 East Redwood Street, Suite 1300
Baltimore, MD 21202

410-767-3670 (within MD)
800-305-6441

info@md-council.org

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Content developed by: Brian Cox

Office of Legislative Audits Fraud Hotline

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This project 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 $1,265,982 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.

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