WE ARE INVITING FUTURE COMMUNITY LEADERS

TO ATTEND THE ANNUAL COLLEGE STUDENT LEADERSHIP FORUM FOR STUDENTS WITH DISABILITIES

July 24th – July 27th, 2009

AT

IOWA STATE UNIVERSITY, AMES IOWA

 

 

·        College juniors and seniors and Vocational/Technical students with disabilities will be selected to attend.

·        College Leadership Forum for Students with Disabilities will pay for the following appropriate expenses:

Þ    lodging

Þ    food

Þ    accommodations for student delegates to attend including but not limited to:  interpreters, alternative format materials, personal care attendants

Þ    scholarships based on need to defray travel expenses to the forum can be provided

·        This 4 day leadership training program includes:  meeting with community leaders with disabilities, and hearing from speakers and employers about issues pertaining to your employment.

 

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APPLICATION FORM

DEADLINE FOR POSTMARK ON MAILED APPLICATION: End of April, 2009.

            (but please do contact us if you need more time)
P Alternative formats accepted.

P Complete ALL information on pages 1 through 4 of this application.

P Please type or print with black ink.

P Mail the application to the address on the last page (page 4).

P Please see Pages 5-6 or insert for additional application information.

 

A. PERSONAL INFORMATION                                                                            Date:___________________             

 

1. _________________________________________________ ______________2.  Male_____  Female _____

    Your Last Name                        First                                          Middle

           

3. Social Security Number____________________________________________________________________

 

4. _______________________________________________________________________________________

    Home Address                                             City                              State                ZIP

5.  Birth date: _________________________________ Date Graduation Expected:_______________________

 

6.  __________________________________________________________________________________________

    College attending                  Address                                    City                           State              ZIP

 

7. ____________________________________________________________________________

    E-mail Address- Please write legibly

 



8. (      )______________________                (      )______________________        (      )___________________

    Home Telephone Number                             College Telephone Number                  Cell Telephone Number


9.  How do you describe yourself? (Please check only one)

            A.  Ethnicity:     [  ] Hispanic                              [  ] Non-Hispanic

B.     Race:          [  ] Black / African                   

                        [  ] Asian / Pacific Islander       

                        [  ] Native American / Alaskan Native, Tribe:_________

[  ] Other: (specify)_____________________________
[  ] White / Caucasian

 

10.  Are you a U.S. Citizen?  Yes [  ]  No [  ]

 

11.  What is your current major? _______________________________________________________________

 

12. Are you currently employed?  Yes [  ] No [  ]    

 

13. If employed, where do you work? ___________________________________________________________                           

     

Please explain your job functions.____________________________________________________________

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________



14. In your own words, describe your disability. (This information will assist in assuring that we include delegates with a diversity of disabilities and match with appropriate mentors.)

      _________________________________________________________________________________

 

      _________________________________________________________________________________

 

      _________________________________________________________________________________




15. Information for Iowa Vocational Rehabilitation Services (IVRS), or Iowa Department for the Blind (IDB)

      If you are currently a client of Iowa Vocational Rehabilitation or Department for the Blind.

 

            IVRS/IDB Counselor’s Name: ______________________________________________________

 

 

 

 

  

 

16. Recommendation forms:

Attached are two recommendation forms.   One form must be completed by a college professor or a college representative and one must be from a community representative outside of your school.  Each form must have an original signature and arrive in a sealed envelope.  Please submit the two sealed envelopes containing the reference forms with this application if possible, or send separately if needed.

 

 

List name, position/title, organization and telephone number of the two people who write these letters.

 

__________________________________________________________________________________

Name                           Title

____________________________________________(         )________________________________

Organization                                                                             Telephone Number

 

__________________________________________________________________________________

Name                           Title

_____________________________________________(       )____________________________________

Organization                                                                             Telephone Number

 


17. School and Community Involvement

            On a separate sheet of paper briefly list your involvement with your school and community (since freshman year). This may include any offices you have held, club memberships, after school activities or work experiences. Include the length of involvement and your class level at the time of participation.  If you are not involved, please give reasons for non-involvement.

 


18. Tell us a little about yourself:

Your responses to the four topics listed below (no more than 500 words) will be used to assess your eligibility to participate in this leadership forum. You may respond by writing your answers on paper, using email, recording your answers on tape, videotape yourself, or come up with other mediums to answer the four topics.  Send your responses along with your completed application packet or make note of electronic responses.

 

            (a)  Qualifications - Explain why you want to attend and why you are qualified to be a delegate at this forum.

            (b)  Positive Influences - In terms of leadership, please tell us about two people who have positively influenced your life. How have they influenced your life? (Families, teachers, counselors, friends, or public officials are appropriate examples.)

            (c)  Experiences as a Person with a Disability - Describe two important experiences you have had as a person with a disability. (Please be specific about your examples as they relate to your disability).

            (d)  Future Plans - Describe your employment/career goals.  Describe you thoughts on how your disability could impact your employment.






 

19. Please use the checklist below to make certain your application packet is complete. All questions must be answered and requested forms and information provided.

 

Required Items

Enclosed

1. Application form (4 pages)

 

2. Two recommendation forms (sealed envelopes)

 

3. Response to four topics

 

4. Transcripts

 

5. School/Community Activity Sheet

 

 

 

 

____________________________________________                    ____________________

Signature of Student                                                                              Date

 

If you would like to have this application packet in an alternate format, please contact (888) 219-0471.

 

Thank you for completing this application. Please mail it to the address below. If you have any questions, please contact:

 

            Iowa Division of Persons with Disabilities

            Attn: CLF Committee  

            Lucas State Office Building

            Des Moines, Iowa  50319

            (888) 219-0471 (V/TTY)

            (515) 242-6172 (V/TTY)

 

(KEEP THIS PAGE, DO NOT MAIL WITH APPLICATION)

           

HOW STUDENTS WILL BE SELECTED AND APPLICATION INSTRUCTIONS FOR STUDENTS

           

1.   To be eligible for the College Leadership Forum, students must:

                  (a)  Have a disability (as defined by the Americans with Disabilities Act);

(b)   Be in your junior or senior year (depending on your situation and other factors, this may be waived) or completing a vocational program as of December 31, 2008;             

                  (c)  Have demonstrated leadership potential in school and the community; and,

(d)   Currently enrolled in an accredited Community College, four-year College or University in Iowa.

 

2.      Student applicants must mail the completed application packet to the Iowa Commission of Persons with Disabilities office--postmarked no later than the End of April, 2008.

 

3.      Semi-finalists will be selected and contacted by telephone to arrange an interview.  Interviews will take place in late May and early June, 2009.

 

4.      All applicants will be notified by letter whether they are selected to attend the forum. (Letters will be mailed by mid June 2009.)   No more than 30 students will be selected to attend.

 

5.      After being selected, students will be asked to fill out a confirmation form and provide additional information.

 

6.   All appropriate expenses will be paid by the College Leadership Forum management, including such expenses as lodging, food, accommodations to attend and participate, and scholarships for travel expenses when needed.

 

GENERAL INFORMATION FOR APPLICANTS:

 

Rules and Guidelines for Student Delegates of the College Leadership Forum

 

In order to provide a fun, safe learning experience at the leadership forum, all delegates will be expected to follow the rules listed below.

 

Students are selected to attend this forum because of their leadership skills and potential.

Consequently, students are expected to demonstrate their leadership ability, and must:

 

            1.   Be punctual.

2.   Be at designated places and stay with your assigned group at all times. Attendance at all general

      sessions is mandatory. 

3.   Maintain a respectful attitude toward peers, counselors and conference staff.

            4.   Respect the facilities (maintaining the condition of dormitory rooms and all other areas). Participants will have to pay for property damage they cause and for lost room keys.

            5.   Smoking and possession or use of illegal chemicals or alcohol are strictly prohibited. (Prescription or other approved medications require verification.)

6.      All other campus residence halls and facilities are off limits unless scheduled by staff and cleared by ISU Conference coordinators. MP3’s, radios and electronic games may be brought to the forum and used during free time only.

7.      Cell phones are permitted but must be turned off in large group and small group settings.

8.      Curfew hours:  All delegates are expected to be in their own rooms by midnight unless waived by staff supervisor.

  

Any violations of these rules will result in students being sent home immediately at your own expense. Your application to the College Leadership Forum indicates your acceptance of these rules and guidelines.

 

AND more importantly, we emphasize that delegates are chosen to attend the forum because of their leadership potential and desire to succeed towards employment. Remember the responsibility that goes with the honor of being selected and plan to have a great time!!