Daring Dialogue Municipal Program Application

Municipal Program Application

Thank you for your interest in disrupting ageism and ableism in your community! This is a common application for our Daring Dialogues and Community Leaders Fellowship programs. Use this form to apply for one or both programs. We accept applications on an ongoing basis and review them in monthly batches. Selection is based on readiness and capacity.
This application takes 10-20 minutes to complete if you have all the information and responses ready. Visit our website ctagewellcollaborative.org to preview the application questions and learn more about Daring Dialogues and the Community Leaders Fellowship programs.

Questions? Contact Christina.Gray@ctcommunitycare.org
Select your Municipality:*
Primary Contact for Application:*

First NameLast Name
Primary Contact Title*
Primary Contact Department*
Briefly describe your challenge/project and why you want to incorporate the lived experience of Fellows? (Up to 200 words)*
Primary Contact Email:*
example@example.com
Primary Contact Phone:*
Please enter a valid phone number.
Which programs are you applying for? Check all that apply.*

Daring DialogueCommunity Leaders Fellowship
How would you describe your logistical capacity to coordinate this program?*

1

2

3

4

5

1 is No Capacity, 5 is Ample
How would you describe your municipality's current work addressing ageism?*

1

2

3

4

5

1 is Not Started, 5 is Advanced
How would you describe your municipality's current work addressing ableism?*

1

2

3

4

5

1 is Not Started, 5 is Advanced

How active are the following resources in your community?

	Very Active	Somewhat Active	Not Active	N/A
DEI Municipal Officer
Senior Center
Municipal Agent for the Elderly
Commission/Advisory on Aging
Disability Services
ADA Coordinator
Commission/Advisory on Disability

Has your municipality partnered with other programs doing similar work? Check all that apply.*

Not, yet!AARP Age-Friendly MemberAARP Livable Communities GrantConnecticut Main Street CenterDementia Friendly AmericaSustainable CTOther

Thank you for taking the time and energy to apply for a Connecticut AgeWell Collaborative's Daring Dialogue and/or Community Leaders Fellowship.

Please click "submit" to complete your application.
Should be Empty:

Municipal Program Application

Daring Dialogue Application

Community Leaders Fellowship Application