BOARD APPLICATION
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Preferred Pronouns
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Phone Number
Cell
Home
Work
Email
example@example.com
Current or Previous Employer (if any)
Current or Previous Job Title (if any)
Please tell us why you are interested in serving on Disability Law Colorado's Board of Directors.
Please describe your personal and/or professional interest and experience in the field of disability rights.
What are the most important skills you will bring to the Board?
Please feel free to attach a resume or bio.
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If you have served on a board before, please tell us about the organization(s), your length of service, and any role(s) you had on the board(s).
DEMOGRAPHIC INFORMATION
Our funders require us to report aggregate demographic information about our Board, staff, and clients. Individual responses will remain private.
Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
Race (select all that apply)
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Two or more races
Unknown or prefer not to say
Gender (select one)
Male
Female
Non-Binary
Other
Prefer not to say
Age (select one)
21 or younger
22-39
40-59
60-79
80+
Prefer not to say
Do you identify as a member of the LGTBQIA+ community (select one)
Yes
No
Prefer not to say
PERSONAL CONNECTION TO DISABILITY RIGHTS
As a Protection & Advocacy agency (42 U.S.C. 15044), DLC must meet these requirements: (B) a majority of the members of the board shall be— i. individuals with disabilities, including individuals with developmental disabilities, who are eligible for services, or have received or are receiving services through the system; or ii. parents, family members, guardians, advocates, or authorized representatives of individuals referred to in clause (i).
Please select all that apply
I have a developmental disability.
I have a physical disability.
I have a sensory disability.
I have a traumatic brain injury.
I have a mental health disability.
I have a disability of another kind.
I receive Social Security benefits and supports because of a disability.
I use assistive technology (such as mobility devices or hearing aids).
I am broadly knowledgeable about disability issues in Colorado.
I am a parent, family member, or guardian of someone
with a developmental disability.
with a physical disability.
with a sensory disability.
with a traumatic brain injury.
with a mental health disability.
with a disability of some other kind.
who receives Social Security benefits and supports because of a disability.
FUNDRAISING
I agree to support DLC with a personal financial contribution appropriate to my circumstances.
Yes
CONFLICTS OF INTEREST
Please affirm by selecting every box that applies
I do not have a relationship with an organization that has a contract with DLC.
I do not hold significant decision-making authority in any organization, company, or governmental entity that serves people with disabilities.
I am not a current state, county, or municipal official.
I have not been a DLC employee within the last five years.
Do you affirm that you are free of these conflicts?
I have no conflicts.
I have potential conflicts that I would like to discuss with DLC.
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