Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814

(855) 894-3436 (voice) for relay services please call 711 ylf@dor.ca.gov (email) Page 1 of 9

CALIFORNIA YOUTH LEADERSHIP FORUM FOR STUDENTS WITH DISABILITIES

2017 YOUTH LEADERSHIP FORUM FOR STUDENTS WITH DISABILITIES DELEGATE APPLICATION

(Event subject to funding availability.)

Only Typed Application Will Be Accepted!

If under 18, my parent/guardian is aware I am submitting this application.

I understand that I must be a Department of Rehabilitation (DOR) Consumer in order to be eligible to be selected to attend. I must be in a DOR plan during the duration of the forum.

Student Information

1. _______________________________________________________________ First Name Middle Last

2. Male Female With which gender do you identify? _________

3. Birth date: ____________________________ 4. ________________________________________________________________

Home address (no P.O. boxes) City Zip code

5. California county of residence: _______________________________________ 6. ________________________________________________________________

Mailing address (if different than above) City Zip code

7. Applicant’s phone number: (____)______________

8. Applicant’s email address: __________________________________________ 9. Parent/Guardian name:_____________________________________________

10. Parent/Guardian’s phone number: (____)_______________

____________________________ _______________________________ Student’s Last Name First Name

11. Parent/Guardian’s email address: ___________________________________

12. Please specify your race and ethnicity from the checklist. Check all that apply:

American Indian and/or Alaskan Native

Asian Group:

Asian Indian Cambodian Chinese Filipino Japanese Korean Laotian/Hmong/Mein Vietnamese Other Asian____________

Black and/or African American

Hispanic and/or Latino

Native Hawaiian or Other Pacific Islander Group:

Guamanian/Chamorro Hawaiian Samoan Other Pacific Islander ___________

White

Other_____________

School Information

13. Name of high school: _______________________________________________ 14. Current grade level: ________________________________________________ 15. Current reading level: _______________________________________________

16. Month and year you plan to graduate: __________________________________

Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 ylf@dor.ca.gov (email)

Page 2 of 9

17. What activities are you involved in? (e.g. student leadership, club memberships, sports, band or other after school activities, volunteer experience, internships, religious activities or work experiences) Add additional pages if needed.

____________________________ _______________________________ Student’s Last Name First Name

A. Name of activity: ___________________________________________________

Name of organization: _______________________________________________ How long have you participated? _______________________________________

B. Name of activity: ___________________________________________________

Name of organization: _______________________________________________ How long have you participated? _______________________________________

C. Name of activity: ___________________________________________________

Name of organization: _______________________________________________ How long have you participated? _______________________________________

Disability Information 18. Please check all that apply to your disability:

Blind/Low Vision

Chemical/Environmental Sensitivity

Chronic Illness (e.g. cancer, cystic fibrosis, diabetes, heart disease, other)

Deaf

Hard of Hearing

Immune (e.g. Crohn’s disease, rheumatoid arthritis, other)

17. What activities are you involved in? (e.g. student leadership, club memberships,

School and Community Involvement

Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814

(855) 894-3436 (voice) for relay services please call 711 ylf@dor.ca.gov (email)

Page 3 of 9

____________________________ _______________________________ Student’s Last Name First Name

Intellectual/Developmental (e.g. acquired brain injury, down syndrome, epilepsy, cerebral palsy, autism/Asperger’s syndrome and other)

Learning (e.g. dyslexia, dyscalculia, attention deficit disorder, other)

Mental Health/Behavioral Health (e.g. anxiety, depression, bipolar disorder, obsessive compulsive disorder, other)

Mobility (e.g. spinal cord injury, muscular dystrophy, other)

Other Disability

19. Name of specific disability(s): _______________________________________

20. Please describe your disability. This information will assist in assuring that we

include a diversity of delegates with disabilities.

21. To assist your full participation at the YLF, please describe your disability or

medical condition so that we may provide the appropriate accommodations.

Blind/Visual Braille Large Print (font size ) Audio Description

Deaf/Hearing I use American Sign Language (ASL) I use Cochlear Implants I use hearing aids or a hearing device

I use Real Time Captioning/ Communication Access Real-time Translation

Other (specify)

Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 ylf@dor.ca.gov (email)

Page 4 of 9

____________________________ _______________________________ Student’s Last Name First Name

Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 ylf@dor.ca.gov (email)

Page 5 of 9

Communication Disability: Please tell us the specifics of your disability so

we can better assist you (such as additional time for responses):

Learning Disability: Please tell us the specifics of your disability so we can

better assist you (such as reading or writing):

Emotional/Psychiatric Disability: Please tell us the specifics of your

disability so that we can better assist you (such as quiet time):

Mobility Limitation: Please tell us the specifics of your disability so we can

better assist you (such as assistance turning pages):

Can you easily walk up stairs (to second floor lodging)? Yes No Check all that apply:

I use a manual wheelchair I use a motorized wheelchair I use a walker I use crutches I use a manual scooter I use a power scooter

Special Equipment needed that I will be bringing (such as a walker, wheelchair, and braille/tablet):

Special Equipment needed on-site that I will NOT be bringing (such as a

Hoyer lift, shower chair):

____________________________ _______________________________

tudent’s Last Name First Name

Personal Care Attendant needed. List (in detail) your needs such as feeding, dressing, toileting, bathing, or over-night asssitance.

Job Experience 22. If you work (paid or volunteer), where do you work and what do you do?

23. How many hours do you work each week? ______________________________

24. List any other employment opportunities you have had.

25. What are your plans after high school?

26. What career fields are you interested in?

27. Are you interested in pursuing a career in Science, Technology, Engineering and Math (STEM)? If yes, which one?

S

Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 ylf@dor.ca.gov (email)

Page 6 of 9

Programs and Services You Currently Receive 28. Department of Rehabilitation (DOR):

If you are currently a client of the DOR, please list: DOR Branch Office: _____________________________________________ DOR Counselor’s Name: _________________________________________ DOR Counselor’s phone number: (____) __________________ DOR Counselor’s email address: ___________________________________

29. Transition Partnership Program (TPP): If you are currently in a TPP, please list: Program School/Site: ____________________________________________ Transition Counselor’s Name: _____________________________________ Counselor’s phone number: (____) ______________________ Counselor’s email address: _______________________________________

30. Regional Centers (RC): If you are currently receiving services from a RC, please list: Name of Regional Center: ________________________________________ Case Manager’s Name: __________________________________________ Case Manager’s phone number (____) ______________________ Case Manager’s email address: ____________________________________

Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 ylf@dor.ca.gov (email)

Page 7 of 9

If you are a DOR, TPP, or RC client, please tell your counselor you are applying for the YLF.

____________________________ _______________________________ Student’s Last Name First Name

Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 ylf@dor.ca.gov (email)

Page 8 of 9

Essay: Tell Us About Yourself Please attach your answers to the following questions in 1-3 typed, double-spaced pages. Please use size 14 font. We would like you to tell us about yourself, your leadership potential and what ideas you have as a future leader of California. Area #1: Autobiography Describe your experience as a youth with a disability and how it has impacted the person you are today. Area #2: Leadership Has your disability shaped you as a leader and in what ways? Area #3: Your vision for the future Tell us how you plan to shape your future?

Legislative Information A. __________________________________________ ___________________

State Senate Representative’s Name* District Number

B. __________________________________________ ___________________ State Assembly Representative’s Name* District Number

* You can find this info at http://findyourrep.legislature.ca.gov/

Letter of Recommendation In order for us to learn more about your leadership skills, attach one or two letters of recommendation. The letters can be from a high school teacher, counselor, administrator, or from a community representative outside of your school. Letters from a relative or family member will not be considered.

____________________________ _______________________________ Student’s Last Name First Name

Final Preparation

Please use the checklist below to ensure your application packet is complete. Incomplete applications will not be considered.

Required Items Completed 1. Completed Application 2. Essay 3. One or two Letters of Recommendation

Did anyone assist you in completing this application? Yes No

If yes, please specify who: _________________________________________

Which parts: ____________________________________________________ How did you hear about the YLF? ________________________________________ May we share your contact information with the Youth Organizing (YO!)? Disabled and Proud http://yodisabledproud.org/ Yes No By accepting attendance to the YLF, you allow the YLF and its affiliates to use your image and/or quotes without compensation while still holding privacy when requested (e.g., blurring out names on badges in photos and using first name and last initial like “John S.' instead of the full name for quotes). By submitting this application, my parent/guardian and I, authorize this application to be confidentially reviewed by an interviewer and a selection panel which is comprised of the YLF partners. ____________________________________________ _________________ Signature of Student Today’s Date ____________________________________________ _________________ Signature of Parent or Guardian (if student is under 18) Today’s Date

Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 ylf@dor.ca.gov (email)

Page 9 of 9

Please print, sign and mail to the address on the YLF Instructions document.

Thank you for completing this application. Please e-mail it to: YLF@dor.ca.gov.

If you need additional assistance in submitting your application, please contact us (855) 894-3436 (voice) For relay services please call 711 ylf@dor.ca.gov (email) Please keep a copy of the application packet for your records.

____________________________ _______________________________ Student’s Last Name First Name