* indicates required field

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1 Application All applications are due midnight January 22, You may start your application and resume at a later time. In order to save your application, you must choose Save & Resume Later, otherwise you will lose your data. Once you choose Save & Resume Later you will see a link. Please copy the link and save it to either your favorites or send it to yourself in an to retrieve at a later date. Your incomplete application will be saved for 7 days. * indicates required field Name * First Last Title/Role * Organization/Program * Address * Street Address Address Line 2 City State / Province / Region Postal / Zip Code Phone * Fax * # # Accommodations I am deaf or hard or hearing I am blind or have low vision I am an individual with a disability If you are selected, we will contact you to obtain information on how we might best support your participation. Experience with Cultural Diversity and Cultural and Linguistic Competence in your Setting Our ideal candidates are those who can describe the challenges and opportunities faced in promoting cultural diversity and advancing and sustaining cultural and linguistic competence (CLC) in the intellectual and developmental disabilities (I/DD) network, and who are committed to grow in their leadership to achieve this goal. Please provide a brief response to the following prompts.

2 1. Tell us about your current or potential leadership role in your community, organization, or setting. * 2a. Share with us your interest in promoting cultural diversity. * 2b. Share with us your interest in advancing and sustaining CLC. * 3. Share any activities in which you are currently participating that promote cultural diversity and/or that advance and sustain CLC. * 4. How will your community, organization, or setting benefit from your participation in this Leadership Academy? * 5. Indicate the primary organization/program with which you are affiliated. (Check only 1) * Center for Independent Living (CIL) MCHBfunded Training Program National/State advocacy organization National/State selfadvocacy organization National/State family organization National association Other* Other AIDDfunded program* Other Federal, State, County or Local Government* Protection and Advocacy Agency State Councils on Developmental Disabilities State, County, Local School System State or County Developmental Disabilities Government Agency* University Centers for Excellence in Developmental Disabilities (*) Please specify *

3 6. Primary geographic/jurisdictional scope of your organization/program. (Check all that apply) * 7. Geographic area of focus of your organization/program. (Check all that apply) * Local County State Tribal Territorial National International Urban Suburban Rural Frontier Other Other (please specify) * 8. Does your organization/program provide direct services and supports to individuals with I/DD? * Yes No IMPORTANT! Please note: If you replied YES, please complete the next section. If you replied NO, you will be automatically taken to the Agreements section of the application. Next Page Save & Resume Later 1 / 3

4 * indicates required field ORGANIZATIONS/PROGRAMS PROVIDING DIRECT SERVICES AND SUPPORTS Please provide the following information for organizations/programs that offer direct services and supports to individuals with I/DD Age Group (Check all that apply) Children & Adolescents (birth 17 years of age) Adults (18 years 65 years) Seniors (65 years and over) Race and Ethnicity Our organization/program does not collect race and ethnicity data for individuals and families receiving services and supports. Ethnicity Race (check all that apply) What are the top three racial or ethnic groups served/supported by your organization or program? Hispanic, Latino/Latina, or Spanish origin White Black or African American American Indian or Alaska Native Asian Native Hawaiian Other Pacific Islander Two or more races Some other race Language What percentage of individuals served/supported use American Sign Language?

5 What percentage of individuals served/supported have limited English proficiency? What percentage of individuals served/supported are English language learners? Next Page Previous Save & Resume Later 2 / 3

6 * indicates required field Letter of Commitment from your Organization AIDD requires that all applicants affiliated with an organization or program submit a letter from their director or appointed leader. The letter should indicate both, the organization's or program's commitment to cultural diversity and CLC and, its support for the individual applying for this Academy. The letter of commitment can be submitted with your application or separately to Donna Deardorff Donna.Deardorff@georgetown.edu no later than midnight January 22, Please upload your letter of commitment below. The accepted formats include PDF, DOC, DOCX. File Upload Choose File No file chosen Agreements * Yes I agree that I will be able to accomplish all of the prework (requiring an estimated of hours over 3 months including coaching, written assignments, 2 webinars and reading) prior to the start of the Academy. I agree that I will: (1) be able to attend and remain focused for all 4 days of the Academy in Santa Fe; (2) plan to minimize personal, family, and professional distractions accordingly; (3) and plan to leave on Friday or later after the Academy Submit Previous Save & Resume Later 3 / 3