Maine Developmental

Disabilities Council

Membership Application Form
  1. Name(*)
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  2. Address Line 1(*)
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  3. Address Line 2
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  4. Primary Phone #(*)
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  6. Additional Phone #
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  8. Additional Phone # 2
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  10. Email(*)
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  11. Please check either "yes" or "no" for each of the following:

  12. A) Person with a developmental disability (DD)(*)
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  13. B) Parent/guardian of a child under 18 years old who has DD(*)
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  14. C) Immediate family/guardian of an adult who has DD(*)
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  15. D) Member or employee of a local and/or non-governmental agency, or a non-profit group concerned with services for persons with DD and their families in Maine(*)
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  16. E) Employed by a State agency that provides services for children and/or adults with developmental disabilities(*)
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  17. Please respond to each of the following questions.

  18. A) How did you hear about the Maine DD Council?(*)
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  19. B) Why do you want to be a member of the Maine DD Council?(*)
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  20. D) What strengths and/or skills will you bring to the Council? (Examples: strong self-advocate, advocacy experience, experience with strategic planning, management, or communications, knowledge of the legislative process, personal commitment, etc.)(*)
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  21. E) Will you be able to make the necessary time commitment involved in being a member of the Maine DD Council? Please briefly explain(*)
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  22. (Please Note: The full Council meets bi-monthly (6 times) throughout the year. In addition, members are required to serve on at least one committee, which may meet as frequently as once a month. Members are expected to review materials and information sent by Council staff in preparation for meetings.)

    References

    Please provide two references we can contact for a recommendation. These should be individuals who know you personally and/or professionally and would be able to comment on the strengths, skills and experience you would contribute as a member of the Council.

  23. Reference 1 Name(*)
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  24. Reference 1 Primary Phone(*)
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  26. Reference 1 Email
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  27. Reference 1 How do you know this individual?(*)
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  28. Reference 2 Name(*)
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  29. Reference 2 Primary Phone(*)
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  30. Type
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  31. Reference 2 Email
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  32. Reference 2 How do you know this individual?(*)
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  33. Please feel free to contact the Council at 207-287-4213 or 800-244-3990 if you have questions or would like additional information.

Newsletter Signup

Now Available

MDDC will now offer Developmental Disabilities Health Technical Assistance through email.  You can email your DD Health related questions to DD Health Help.  Check out the flyer for more information.

DD Health Technical Assistance Flyer

Maine Developmental Disabilities Council
225 Western Avenue, Suite 4
Augusta, ME 04330
Phones: 207-287-42131-800-244-3990