PIP Application - Virginia Board for People with Disabilities

Instructions

Before beginning, please read ALL of the instructions, questions, eligibility definitions, submission requirements, and important information included on this form. If you have ANY questions or need accommodations to complete this application form, please contact the Virginia Board for People with Disabilities (VBPD).
Applicants must complete ALL sections of the application form and return it to the VBPD by the deadline for it to be considered. Application forms must be received no later than 5:00 p.m. on Friday, March 14, 2025 to be considered for the 2025-2026 PIP class.
Submission online (below) is preferred. Applications will also be accepted by email, fax, or mail. Information on how to complete and submit the application is included in the instructions below the online form.

APPLICATIONS SHOULD BE RECEIVED NO LATER THAN
FRIDAY, MARCH 14, 2025 BY 5:00 P.M.
TO BE CONSIDERED FOR THE PIP 2025-2026 CYCLE.

Online Submission Form

Applicant Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Alternate Email

Phone(Required)

Alternate Phone

Date of Birth(Required)

mm/dd/yyyy

Ethnicity(Required)

Gender(Required)

Male

Female

Photo Upload

Accepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 64 MB.

Please upload a photo of the applicant (optional)

References

Please list three references and have each complete a Letter of Recommendation Form. References can complete the form online or download and email their form to: training@vbpd.virginia.gov. Letter of Recommendation Forms must clearly identify the individual being recommended.

Important: The Letter of Recommendation Forms must be received by the Virginia Board for People with Disabilities by 5:00 p.m. on Friday, March 14, 2025.

Reference 1 Name(Required)

Full Name

Reference 1 Phone(Required)

Reference 1 Email(Required)

Reference 2 Name(Required)

Full Name

Reference 2 Phone(Required)

Reference 2 Email(Required)

Reference 3 Name(Required)

Full Name

Reference 3 Phone(Required)

Reference 3 Email(Required)

Definition of Developmental Disability

(A) In general, developmental disability means a severe, chronic disability of an individual that:

is attributable to a mental or physical impairment/combination of mental and physical impairments;
is manifested before the individual attains the age 22;
is likely to continue indefinitely;
results insubstantial functional limitations in three or more areas of major life activity, such as self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency; and
reflects the individual’s needs for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are lifelong or for an extended duration and are individually planned and coordinated.

(B) An infant or young child (an individual from birth to age nine) who has substantial developmental delay, a specific congenital, and/or an acquired condition may be considered to have a developmental disability without meeting three or more of the criteria described in the clauses (i) through (v) in subparagraph (A) if the individual, without services and supports, has a high probability of meeting those criteria later in life.

Eligibility

The VBPD uses the above definition of developmental disabilities to determine eligibility for participation in PIP.

Are you a person with a developmental disability?(Required)

Yes

If so, please briefly describe your disability and how it affects your activities of daily life.(Required)

Are you a parent of a child with a developmental disability?(Required)

Yes

If not, please specify the relationship you have with him or her below.(Required)

What is the age of your child?(Required)

Briefly describe your child’s disability/disabilities and how his or her activities of daily living are affected.(Required)

Questions

Please be concise with your responses. You may seek assistance to complete your application. If you need to submit your responses in another format, the VBPD staff is happy to work with you.

Please tell us a little about yourself and family.(Required)

Please tell us about your views on community inclusion and integration.(Required)

What does the word advocacy mean to you? When have you demonstrated advocacy skills?(Required)

When have you been creative in getting services for yourself or someone else? How?(Required)

Advocacy can be an ongoing process. Tell us about an experience that shows your determination.(Required)

What would you like to see change in the current service delivery system? Please be specific and give details.(Required)

Tell us about your strengths and any unique experiences you have had.(Required)

List activities in which you regularly participate (employment, volunteer work, community service, board assignments, etc.).(Required)

Tell us about something you have done that shows you can complete a long-term project and share information with others.(Required)

What do you hope to gain from Partners in Policymaking?(Required)

How did you hear about PIP?(Required)

Participation Requirements

PIP participants are people with developmental disabilities and/or parents of young children with developmental disabilities. Individuals participating in the program will attend advocacy training and skill-building workshops. Program participants will attend and participate in seven two-day sessions between September and April. Completion of this application and selection for the PIP program requires substantial commitment of time, motivation, and energy.

If accepted into the PIP program, I agree to:

Attend and participate in ALL seven two-day sessions (sessions begin Friday at 1:00 p.m. and concludes Saturday at 3:00 p.m.).
Complete all homework and class assignments.
Complete one major project designed to meet competencies.

DISCLAIMER:

This year’s PIP Training Program will be delivered in an hybrid format. Of the seven PIP sessions, 3 are scheduled to be held In-Person (September 2025; March and April 2026) at the selected hotel site that will be released in early 2025. The remaining 4 PIP Sessions will be held via ZOOM. We encourage all applicants to consider these PIP Session dates and to be flexible as we incorporate this hybrid approach: in-person and virtual meetings during the PIP 2025-2026. PIP Sessions held on Fridays (beginning at 1:00 p.m.) and Saturdays from 8:30 a.m.- 3:00 p.m.). The Virginia Board for People with Disabilities will keep all applicants informed regarding any changes to the PIP Session schedule.

I give permission to the Board to share the answers to the questions on this application with PIP staff and members of the selection committee.

By entering my name below, I certify that I am the applicant represented by the information on this application, as well as guarantee that all of the information provided is accurate to the best of my knowledge and has been voluntarily disclosed. For the purpose of the PIP application submission, the insertion of your name on the signature line qualifies as an electronic signature.

Signature(Required)

Please type full name to agree to terms.

Date(Required)

Did you remember to:

Complete ALL sections of this application. Applications with incomplete sections will NOT be considered.
Ask three references to complete Letters of Recommendation Forms (Forms must be received by the application deadline).
Include any additional pages.

Email Submission

Download the application form.
Answer each of the questions on the application form by filling in the blanks provided and/or checking the appropriate circles. If you need to stop and start again later, remember to save the file before closing it so that you do not lose the answers to the questions that you have already completed.
When you have finished completing the application form, save it. Prior to returning the application by email, be sure to include your electronic signature with your assurance that you are the applicant and that you have voluntarily supplied the requested information. For the purpose of the application submission, the insertion of your name on the signature line qualifies as an electronic signature.
Attach the saved file containing the completed form to a new email message and send it to training@vbpd.virginia.gov.

Fax Submission

Option A

Download the application form.
Save and complete the form on your computer.
Print the completed form.
Fax all pages of the completed form to 804-786-1118.

Option B

Download the application form.
Print the form.
Complete the printed copy of the application form by hand.
You may attach pages with numbered responses, if necessary.
Sign the application form signature page.
Fax all pages of the completed form to 804-786-1118.

Mail Submission

Complete the application form using either Option A or B above.
Sign the application form signature page.
Mail or deliver all pages of the completed application, including the signed copy of the signature page, to:

Partners in Policymaking
Virginia Board for People with Disabilities
Ratcliffe Building
1602 Rolling Hills Drive, Suite 100
Richmond, VA 23229

Accommodations

If you need an accommodation to complete this form, email training@vbpd.virginia.gov or call 800-846-4464 or 804-786-3441 to speak to a Training Program Coordinator. Unless accommodations are requested, only online, emailed, faxed, and mailed applications will be accepted. We strongly encourage online submission using the form on this page.