2012 Advocates in Disability Award (ADA) Application

Applicant´s Name:

Applicant´s Date of Birth:



Applicant´s Mailing Address:



Applicant´s Phone Number:



Applicant´s Email Address:



Please specify your disability(s):



Please respond to the following questions (responses should be enclosed in the application):

In 500 words or less, please describe yourself and your current/previous work which impacts/impacted the lives of individuals with disabilities.



In 600 words or less, please describe the project that you would develop and/or expand and implement with up to $7,000 in funding. The project should serve and empower individuals with disabilities.



Each applicant must submit two (2) letters of reference or support from individuals familiar with the applicant’s work that positively impacts the disability community.

Reference #1 - Name

Reference #1 - Email

Reference #1 - Letter of Reference

Reference #2 - Name

Reference #2 - Email

Reference #2 - Letter of Reference



Does your proposed project involve partnering with an organization(s)?
Yes
No

If the implementation or expansion of your project involves partnering with an organization, you must submit a partnership letter from the organization(s) involved.
If applicable, Upload Your Partnership Letter Here




If you prefer to complete your application in MS Word or PDF format, upload your application here.


Semi-finalists will be contacted for phone interviews.

By submitting an application, you are confirming the following:

• You are between the ages of 14 and 26
• You are a person with a disability
• You currently reside in the United States
• You are not an employee of the HSC Health Care System or a family member/member of its Board of Directors or the National Youth Transitions Collaborative Leadership Council
• You are able to attend the ADA/NYTI Briefing Reception on June 7, 2012 in Washington, DC
• If selected, you are willing to participate in a monthly conference call with a staff member of The HSC Foundation (HSCF) and provide status updates on your project
• If selected, you will provide HSCF with an interim progress report (by December 3, 2012), and a final report (by May 31, 2013) detailing the project’s successes and outcomes, as well as challenges and barriers. The final report shall also include an accounting of all expenditures for the project
• You will make every effort to promote the Advocates in Disability Award (ADA) Program and the National Youth Transitions Center in your advocacy work, including your participation in various HSCF activities and/ or activities arranged by HSCF
• You are providing permission to The HSC Foundation to use photos and materials related to you and your ADA project for marketing/PR, education, and promotional purposes

Incomplete applications and/or applications without two (2) letters of reference and partnership letter(s), if applicable will not receive consideration.