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moDDRC overview

SOS also provides peer matches for individuals with disabilities, extended family members or professionals.

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Apply to Be a Mentor/Volunteer

There are many opportunities to volunteer, no matter how much time you have or what your background - from peer support to product review, volunteer now.

Volunteer Application
Date: / MM / DD / YY
First Name:
Last Name:
Street Address:
Street Address 2:
City:
State:     Zip:
County:
Home Phone:
Work Phone:
Other Phone:
Email:
Can you accept calls at work? Yes   No
Preferred times to be contacted: AM   PM Any
How do you prefer to be contacted? Phone   Email   Mail  
What is your relationship to the person with a disability?
Mother Father
Sibling Grandparent
Self-Advocate Other Family Member
Friend Professional
Other:
If other, please describe:
Opportunity Interests
Please read through the following list of leadership/volunteer opportunities and place a check mark by those you are interested in (you can check as many as you would like).
 Information
Review or write products (e.g., provide a written personal perspective on your experience with disability for the website; or share information about a particular disability or related topic).
Display Assistant (taking MODDRC display and handout materials to conferences, transition fairs, back to school fairs, community events).
 Peer Support
Be an SOS mentor
Quick match (a match consisting of one phone call that focuses on a particular issue or question)
Traditional match (a match consisting of a minimum of four contacts by phone or email over an eight week period)
Extended match (an ongoing match over a one-year period, with minimum of once-monthly contact)
 Leadership:
Advisory Boards (from time to time there are opportunities to serve on advisory and other types of boards that pertain to developmental disabilities. Often, a parent or self-advocate is sought, and you could be informed as these opportunities arise).
Educational Awareness Activities (e.g., providing testimony, talking to others about your experiences with disability, assist as a trainer or presenter at conferences).
Community Organizing (e.g., support group start-up, organize community leaders around specific issues or areas of interest).
Quality Assurance:
 
 Please indicate other ways you would like to be involved that are not shown above?
Language/Ethnicity
Main language spoken at home:
Other language(s) spoken:
What is your ethnicity?
African American Asian
Hispanic Native American
Caucasian Multi-ethnic
Prefer not to say Other:
If other, please describe:
Marital Status
What is your marital status? Single   Married / Partner   Divorced   
Widow/Widower    Prefer not to say  
About the Person with a Disability
First Name:
Last Name:
Birth date: / MM / DD / YY
Gender: Male   Female
Primary Diagnosis:
Secondary Diagnosis:
Other Diagnosis:
School District, if applicable:
Other disabilities, special healthcare needs, or concerns:
Person with disability currently resides:
How long:
Other Family Members with a Disability
First Name:
Last Name:
Birth date: / MM / DD / YY
Gender: Male   Female
Primary Diagnosis:
Secondary Diagnosis:
Other Diagnosis:
Please List the Birth Year(s) and Gender(s) of Siblings Without Disabilities:
Birth year: Gender: Male   Female
Birth year: Gender: Male   Female
Birth year: Gender: Male   Female
Birth year: Gender: Male   Female
Birth year: Gender: Male   Female
Birth year: Gender: Male   Female
Please Indicate if You Have Attended / Completed Any of the Following (check all that apply):
Partners in Policymaking Program Year Completed: State Attended:
MPACT Advocacy or Mentor Training Year Completed: State Attended:
Any other mentor, peer support, or advocacy training? Type of training:
 Location:
Who provided the training?:
Have you advocated for your own or someone else's rights, needs, etc? Please explain:
Have you provided peer support for another parent or self-advocate? Please explain:
Sharing Experiences
Please check all of the following that you or your child has had experience with and you feel comfortable discussing with another parent:
 Medical
Botox injections
Dorsal rhizotomy
G-tube feeding
Gavage feeding
Home nursing care
NICU/PICU
Pre-natal diagnosis
Premature birth
Shunting
Seizures
Sleep issues
Special Diets
Surgeries/Procedures
Tracheostomy
 Sensory
(Visual) wears glasses
Moderate visual impairment
Severe visual impairment
Functionally blind
 Mobility
Ambulatory
Non Amulatory
Uses wheelchair
Uses walker, cane, assistive device
Other, if other, please describe:
 Behavior
Challenging behaviors
Positive behavior support
Self-injurious behavior
 School
Daycare
Transition to school age services
Early childhood special education
Classroom inclusion
Self-contained education setting
Home schooling
IEP issues
Accomodations/adaptations
Transition from school to adult life
 Communication
Typical language development
No formal communication
Does not use spoken language
Uses sign language
Speaks, but difficult to understand
Uses communication system
Classroom inclusion
Uses assistive technology
Uses facilitated communication
 Living Arrangements
Family home
Foster home
Own home or apartment
ISL
Group home
ICFMR
Habilitation Center
Nursing Home
 Legal
Legal rights
Guardianship, options and alternatives
Conservatorship
Living will
Special needs trust
Estate planning

 

Surgeries or medical procedures, please specify:
Special diet, please specify:
Sharing Experiences, Part 2
Please check all of the following items that you have experience with:
 Therapy
HBO therapy
Physical therapy
Occupational therapy
Speech & language
Sensory integration
Music therapy
Orientation & mobility
Applied Behavior Analysis (ABA)
Hippotherapy (horseback riding)
Behavior therapy
Manual therapy
 Other
Adaptive equipment/assistive technology
Advocacy
Sibling relationships
Recreation
Community inclusion
Grandparent relations
Respite care
Relationships
Transition to Community Living
Medicaid waiver (Lopez, home/community, etc.)
Guardianship options and alternatives
Adaptive equipment/assistive technology, please specify:
Communication devices, please specify:
Are there any other topics or areas of expertise you feel confident speaking about with another parent?
Questions / Comments

 
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