Self Determination Menu About Application Employment Gateway Self Determination Initiative Application Thank You! Your form submission has been successfully sent. Downloadable Application Form Application - Word Format Application - PDF Application About You First Name Last Name Address City State Zip How do you prefer that we communicate with you? Please Select Phone Email Either Phone or Email Phone Number Email Address Eligibility Questions I live in Jefferson county. Yes No I am 18 years of age or older. Yes No Application Questions Describe your goal(s). How do you plan to use Self-Determination support to achieve long-term success? Have you talked with your team (family, friends, Resource Coordinator, others) about your goals? What other available resources have you identified? Have you applied and/or been approved for Self-Determination before? Yes No Plan Supports and Cost What items or supports are you requesting to reach your goals? Please note specifics if you have a program or provider in mind. Please use the following fields Name/DescriptionCost/UnitTotal Cost Long Term Planning Self-Determination is set up to provide short-term financial support as you’re working toward a goal. We ask that after a request is approved, you identify other resources available for any ongoing, long-term support. What plans do you have to sustain progress toward your goals when Self-Determination funding concludes? Thank you for taking the time to tell us about your plans for the future. Please submit your completed application to a DDRC Resource Coordinator or Self-Advocacy Coordinator. You will receive a letter, typically with in 45 days, explaining what will and will not be paid for and the reason why. Funding for this project is approved on an individual basis. The Self-Determination Allocation Committee will review and approve applications based on funds available. All funds must be spent by June 30th 2018.