July 23rd July 26th, 2004





        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:



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

    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.





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 Division of Vocational Rehabilitation Services (DVRS), or Iowa Department for the Blind (IDB)

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


DVRS/IDB Counselors 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.



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


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)




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 or completing a vocational program as of December 31, 2003;

(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 February 27, 2004.


3.      Semi-finalists will be selected and contacted by telephone to arrange a personal interview. Interviews will take place in late March and April, 2004.


4.      All applicants will be notified by letter whether they are selected to attend the forum. (Letters will be mailed by the end of April 2004.) 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.




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. Walk-mans, 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!!