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Quarterly Council Meeting: October 24-25, In-Person - Atlanta

GCDD Council Member Application

Applying for appointment to the 28-member Council is a true form of advocacy. If you are appointed to the Council, all members are responsible for attending four quarterly meetings, held virtually or in-person. Members are reimbursed for lodging, meals and mileage to attend meetings. Applicants should have first-hand knowledge about develomental disabilities (DD) in Georgia.

To apply, please complete an application and email, mail, or submit online to GCDD. GCDD accepts applications year-round. If you have any questions regarding applying to the Council or completing this application, please email us at .

The online application is available below. The application is also available in the following formats:

Applications can be submitted online; emailed to  with “Council Member Application” in the subject line; or mailed to the GCDD offices at:

Georgia Council on Developmental Disabilities
Sloppy Floyd Building, West Tower
200 Piedmont Avenue SE
Suite 426, 4th Floor
Atlanta, GA 30334
Attention: Fanta Mitchell

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Section I - Biographical Information

Name *

Residence Address *
Mailing Address (if different from Residence Address.)
Email *
Birth Date (mm/dd/yy)
Phone Number (###-###-####)
Race/Ethnicity *
Gender *

Geographical Information

What area of Georgia do you live in? Please check your region based on the map.

Please select your region based on the map above.
Region 1 - North Georgia
Region 2 - East Central Georgia
Region 3 - Metro Atlanta
Region 4 - Southwestern Georgia
Region 5 - Southeastern Georgia
Region 6 - West Central Georgia
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Section II: Relationship to People with Developmental Disabilities

Developmental disability is defined as: a significant, chronic disability that begins before age 22 and is likely to continue throughout life. A developmental disability has a major impact on the person’s life in at least 3 of the following areas:

  • Self-care
  • Language
  • Learning
  • Mobility
  • Self-direction
  • Capacity for independent living
  • Economic self-sufficiency

Please note: In this section, the word Institution is defined as: a place that provides food, shelter, and some treatment or services to four or more people not related to the administrator.

 

Please select all that applies.

GEORGIA RESIDENT WITH DEVELOPMENTAL DISABILITIES

I am a Georgia Resident with a developmental disability.
Yes
Please tell us how your disability impacts you.
Have you ever lived in an institution, or do you live in one now?
Yes
No
I am not sure.

PARENT, FAMILY MEMBER, or LEGAL GUARDIAN OF A GEORGIA RESIDENT WITH DD

I am a Parent, Family Member, or Legal Guardian of a Georgia Resident (under age 18) with a Developmental Disability. , familiar o tutor legal de un residente de Georgia (menor de 18 años) con una discapacidad del desarrollo.
Yes
Please tell us how the child’s disability impacts them.
Has the child with a developmental disability ever lived in an institution, or do they live in one now?
Yes
No
I am not sure.
I am a Parent, Family Member, or Legal Guardian of a Georgia Resident (18 or older) with a Developmental Disability.
Yes
Please tell us how your adult relative’s disability impacts them.
Has your adult relative ever lived in an institution, or do they live in one now?
Yes
No
I am not sure.
REPRESENTATIVE OF A NONPROFIT ORGANIZATION OR AGENCY
Yes
Please specify the organization or agency you are representing. (Note: if your application is selected for membership, membership will be in the name of the organization or agency, rather than a specific individual.)
Address of Organization
How does your organization support people with developmental disabilities in Georgia?
Is this organization:
A Non-Governmental Organization (NGO) – defined as an organization not under Government control, that according to federal law cannot be religious or military in nature.
A nonprofit organization – defined as a private non-profit with a voluntary board
Both a non-governmental and non-profit organization
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Section III: Membership to the Georgia Council on Developmental Disabilities

If you are applying on behalf of an organization, please substitute “your organization” for “you” in the questions below.

Does your employer receive funds from GCDD?
Yes
No
If yes, what is your job title?
Have you ever served on the Council?
Yes
No
If yes, when did you serve on Council?
Why do you want to become a member of the Georgia Council on Developmental Disabilities? *
What strengths do you bring to the role of council member? *
What is your experience with improving the lives of people with developmental disabilities? This may include volunteer experience, advocacy, and any work with community. *
What are your ideas to improve the lives of Georgians with developmental disabilities and their families? *
Do you require any accommodations to participate as a Council member? If yes, describe accommodations needed (accessible transportation, personal care provider, interpreter, facilitator, special dietary requirements, etc,) *
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Section IV: Signature

I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization will be for use by the Georgia Council on Developmental Disabilities in determining my suitability for appointment to the Georgia Council on Developmental Disabilities. 

 

By entering my name below I understand that I give the Georgia Council on Developmental Disabilities permission to do a background investigation on me. This investigation will be used to determining my suitability for appointment to the Georgia Council on Developmental Disabilities. 

Applicant's Full Printed Name *
Date *
Submit
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