ALABAMA RESIDENT?
YesNo

GENDER
MaleFemaleNonbinaryPrefer to Self-DescribePrefer Not to Say

RACE
AsianBlack or African AmericanHispanic or LatinoNative American, American Indian, or Alaska NativeNative Hawaiian or Other Pacific IslanderWhite or CaucasianOther or Prefer to Self-Describe

EMPLOYMENT STATUS
EmployedSelf-EmployedNot EmployedOther or Prefer to Describe

HAVE YOU EVER SERVED ON THE COUNCIL?
YesNo

WHICH CATEGORY OF MEMBERSHIP ARE YOU APPLYING FOR?
Person with a Developmental DisabilityA person with a developmental disability who lives or has lived in an institution (Partlow Development Center, nursing home, etc.)A parent or legal guardian of a child with a developmental disability under the age of 18An immediate relative (i.e., spouse, parent, grandparent, brother, sister) or legal guardian of an adult with a mentally impairing developmental disability who cannot advocate for him/herselfAn immediate relative (i.e., spouse, parent, grandparent, brother, sister) or legal guardian of an individual with a developmental disability who lives or has lived in an institutionLocal and non-governmental agency concerned with services for people with developmental disabilitiesPrivate non-profit group concerned with services for people with developmental disabilities

WHAT IS YOUR COMFORT LEVEL WITH SPEAKING BEFORE GROUPS AND MAKING PRESENTATIONS?
Extremely ComfortableComfortableUncomfortable

WHAT IS YOUR COMFORT LEVEL WITH PROVIDING INFORMATION TO STATE AND LOCAL OFFICIALS?
Extremely ComfortableComfortableUncomfortable
DO YOU HAVE COMMITMENTS OR CONFLICTS THAT MIGHT PREVENT YOU FROM ATTENDING QUARTERLY COUNCIL MEETINGS?
YesNoOther or Prefer to Describe

ARE THERE ANY ACCOMMODATIONS YOU WILL NEED TO PARTICIPATE AS A COUNCIL MEMBER?
YesNo


HOW DID YOU LEARN ABOUT THE ALABAMA COUNCIL ON DEVELOPMENTAL DISABILITIES?
Friend or Family MemberWebsiteBillboardAlabama Governor’s OfficeRadioOther