GCDD Council Member Application

Section I - Biographical Information

Name*

Residence Address*

Mailing Address (if different from Residence Address.)

Email*

Birth Date (mm/dd/yyyy)*

Phone Number (###-###-####)*

Race/Ethnicity*

Gender*

Geographical Information

What area of Georgia do you live in? Please check your region based on the map.

Please select your region based on the map above.*

Section III: Membership to the Georgia Council on Developmental Disabilities

If you are applying on behalf of an organization, please substitute “your organization” for “you” in the questions below.

Does your employer receive funds from GCDD?*

Yes

If yes, what is your job title?

Have you ever served on the Council?*

Yes

If yes, when did you serve on Council?

Why do you want to become a member of the Georgia Council on Developmental Disabilities?*

What strengths do you bring to the role of council member?*

What is your experience with improving the lives of people with developmental disabilities? This may include volunteer experience, advocacy, and any work with community.*

What are your ideas to improve the lives of Georgians with developmental disabilities and their families? *

Do you require any accommodations to participate as a Council member? If yes, describe accommodations needed (accessible transportation, personal care provider, interpreter, facilitator, special dietary requirements, etc,)

Section IV: Signature

I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization will be for use by the Georgia Council on Developmental Disabilities in determining my suitability for appointment to the Georgia Council on Developmental Disabilities.

By entering my name below I understand that I give the Georgia Council on Developmental Disabilities permission to do a background investigation on me. This investigation will be used to determining my suitability for appointment to the Georgia Council on Developmental Disabilities.

Applicant's Full Printed Name*

Date*