KPIP Application 2024-2025
APPLICATION FOR PARTICIPATION
Session 1 Dates: September 13-14, 2024 Friday & Saturday, In Person
Session 2 Dates: October 11-12, 2024, Friday & Saturday, Via Zoom
Session 3 Dates: November 8-9, 2024, Friday & Saturday, In Person
Session 4 Dates: January 10-11, 2025, Friday & Saturday, In Person
Session 5 Dates: February 7-8, 2025, 2024 Friday & Saturday, Via Zoom
Session 6 Dates: March 4-5, 2025, Tuesday & Wednesday, In Person
Session 7 Dates: April 11-12, 2025, Friday & Saturday, Via Zoom
Session 8 Dates: May 9-10, 2025, Friday & Saturday, In Person
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Email *
Name *
First and last name
Address *
Phone number *
Do you have a guardian? If so the guardian must complete this paperwork.
Federal Definition of Developmental Disability
CCDD funding requires that beneficiaries have a developmental disability. Please see the definition below: 
According to the Developmental Disabilities Assistance and Bill of Rights Act, the term “developmental disability” means a severe, chronic disability of an individual that:
• is attributable to a mental or physical impairment or combination of mental and physical impairments;
• is manifested before the individual attains age 22;
• is likely to continue indefinitely;
• results in substantial functional limitations in 3 or more of the following areas of major life activity:
o Self-care.
o Receptive and expressive language.
o Learning.
o Mobility.
o Self-direction.
o Capacity for independent living.
o Economic self-sufficiency; and
• reflects the individual’s need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated;
• Infants and Young Children - An individual from birth to age 9, inclusive, who has a substantial developmental delay or specific congenital or acquired condition, may be considered to have a developmental disability without meeting 3 or more of the criteria described in clauses (i) through (v) of subparagraph (A) if the individual, without services and supports, has a high probability of meeting those criteria later in life.
1. Are you a person with a developmental disability? *
a. If yes, please specify your disability and provide information about how it affects your daily life:
b. What kinds of supports services or technology services/devices do you use or do you receive?
2. Are you applying as a family member of a person with a developmental disability? *
a. If so, what services does your family member receive?
b. Check one in each column for each family member with a developmental disability: Person 1
(If no, proceed to Question 3.)
Physical
Cognitive
Emotional/Behavioral
Sensory
Other
Birth - 3 Years Old
4 - 7 Years Old
8 - 10 Years Old
11 - 14 Years Old
15+ Years Old
Clear selection
Check one in each column for each family member with a developmental disability: Person 2
(If no, proceed to Question 3.)
Physical
Cognitive
Emotional/Behavioral
Sensory
Other
Birth - 3 Years Old
4 - 7 Years Old
8 - 10 Years Old
11 - 14 Years Old
15+ Years Old
Clear selection
Check one in each column for each family member with a developmental disability: Person 3
(If no, proceed to Question 3.)
Physical
Cognitive
Emotional/Behavioral
Sensory
Other
Birth - 3 Years Old
4 - 7 Years Old
8 - 10 Years Old
11 - 14 Years Old
15+ Years Old
Clear selection
c. Please specify by child his/her disability and provide information about how it affects their daily life:
(If no, proceed to Question 3.)
d. Please provide specific information on how this diagnosis or disability affects your access to necessary or needed services.
(If no, proceed to Question 3.)
e. Is your family member receiving special education services?
Clear selection
In-person sessions begin at 11 am the first day and end around 4:00 p.m. on the second day. Sessions are held at the CCDD Office - 1024 Capital Center Drive, Frankfort, KY
PLEASE NOTE: The Partners program does not provide on site child care services. Family members are not permitted to stay at the hotel during the training sessions unless a family member is serving as a personal assistant to a class member.
a. Attendance is required at each session. Will you make a time commitment of two days, a month from September through May? *
b. If you are employed, have you talked with your employer about session attendance and made necessary arrangements so you can attend all sessions? *
c. Can you commit to doing a project after graduation? *
6. If you have a disability, what accommodations do you need to help you actively participate in the sessions (such as wheelchair access or larger print)? *
7. Do you require interpreter services (such as American Sign Language (ASL), or other language translation)? *
8. If you are a parent, will you be using respite/child care services so you can participate in the Partners program? *
9. If you are a person with a disability, will you be using personal care assistant (PCA) services during the sessions? *
Please note: The CCDD will reimburse for services but does not provide services. CCDD is a payor of last resort.
10. Are you currently a member of, volunteer for, or involved with, an advocacy organization? *
11. Please tell us about yourself/ your family.
a. If you are working, tell us about your job and the kind of work you do:
b. If you are in school, tell us about the types of classes you are taking:
c. In what type of community/volunteer activities are you involved?
12. Tell us why you want to participate in the Partners in Policymaking program. *
13. How did you learn about the Partners in Policymaking Program? *
Questions about KPIP? Contact Nicole Maher at 502-226-0784 or nicole.maher@ky.gov
The Commonwealth Council on Developmental Disabilities (CCDD) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CCDD does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

A copy of your responses will be emailed to the address you provided.
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