Membership Form

The Developmental Disabilities Alliance of Western New York is a collaborative group of member voluntary agencies that provide services to people with developmental disabilities. While honoring individual agency missions, it is the intent of the Alliance to assist agencies to develop relationships, promote unified strategies and share risks for the mutual gain with and for the benefit of people with developmental disabilities.

Submission of your application constitutes your acceptance of the rules as stated in the enclosed “By-Laws of the Developmental Disabilities Alliance of Western New York” and of the basic principles enunciated in the above mission statement.

ORGANIZATIONAL INFORMATION

Full corporate name(Required)

Program name(s) by which you may also be known:

Contact Name(Required)

First Last

Phone(Required)

Email(Required)

Administrative Address(Required)

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Chief Executive Officer(Required)

First Last

Chief Executive Officer Title

Proposed Representative

First Last

Proposed Representative Title

PROGRAM INFORMATION

How did you hear about DDAWNY?

Are all legally required government certifications/filings current and in good standing?(Required)

— Select One —YesNo

If no, please explain:

Please list accreditations/special licenses, etc. if any. (type, source, date received)

HISTORY AND GENERAL BACKGROUND INFORMATION

Year organization was founded:(Required)

Are you a not-for-profit corporation?(Required)

— Select One —YesNo

Site the document in which the purpose of the agency is formally stated (Certificate of Incorporation, Constitution, Charter or other) and quote the purpose as stated.(Required)

SCOPE OF OPERATION

Include only existing sites and those for which a title/lease has been secured and completion is certain.

Sites of operation(Required)

Number of clients served(Required)

Counties served(Required)

Type(s) of services provided:(Required)

Early Intervention

Preschool

Special Education ages 5 -21

Residential

Adult Day Services

Employment Supports

Day/Residential Habilitation

Clinic Services

Care Coordination

Respite

Family Support Services

Other

Counties your agency services:(Required)

Chemung

Livingston

Monroe

Ontario

Schuyler

Seneca

Steuben

Wayne

Wyoming

Yates

Allegany

Cattaraugus

Chautauqua

Erie

Genesee

Niagara

Orleans

If Other (please specify)(Required)

Number of staff (FTE)(Required)

Agency budget devoted to services for people with disabilities(Required)

Annual Operations Budget(Required)

— Select One —Under $1,000,000- $250$1,000,001 – $7,500,000 – $500$7,500,001 – $10,000,000 – $1,200$10,000,001 – $20,000,000 – $3,200$20,000,001 – $30,000,000 – $5,800$30,000,001 – $40,000,000 – $7,300$40,000,001 – $50,000,000 – $8,800$51,000,001 – $70,000,000 – $9,800$70,000,001 – $100,000,000 – $12,500$100,000,001 and over – $13,500

ADDITIONAL QUESTIONS

Why are you interested in a DDAWNY membership for your agency?(Required)

In what ways do you believe your agency can contribute to the strength and collaborative nature of the Alliance?(Required)

AUTHORIZATION

Consent

I have read the code of ethics below:

DDAWNY member organizations commit to the following prescribed standards and principles of quality, which apply to the supports provided in the professional relationship with persons served, parents and guardians of individuals served, colleagues, related agencies and professions, and the community at large. In abiding by this pledge, it is understood that the member organization views its obligation in as wide a context as the situation requires, taking all the principles into consideration and choosing a course of action consistent with the spirit and intent by which they were created.

AS A MEMBER OF DDAWNY, THIS ORGANIZATION WILL:

• Contribute ideas, findings, concepts, understanding, knowledge and practice to the body of community supports; and support continuing education and expanded knowledge of leading practices in providing supports and services in the field of disabilities;


• Provide supports and services as a public trust that requires integrity, compassion, and respect for individual differences and choice;


• Provide supports and services designed to meet the needs of the individual with emphasis on promoting choice, self-determination, inclusion and accommodation, growth and development;


• Respect the privacy of persons served and protect the rights of confidentiality;


• Give preference to professional responsibility over any personal or organizational interests and provide full disclosure of potential conflicts of interest;


• Advocate for standards that promote outcomes of quality for people;


• Advocate for and provide supports and services that can best assure the health and safety of individuals served;


• Encourage and advocate for the protection of the individual and the community against unethical and/or illegal practices or actions by other individuals or organizations engaged in providing supports;


• Not discriminate because of race, color, religion, age, sex, sexual orientation, disability, or national ancestry, and shall work to eliminate or prevent such discrimination in providing supports and act toward improvement of such situation;


• Promote inclusion and equitable treatment of all people including those receiving supports, staff, friends, families and the public;


• Serve as a responsible steward for public and private funds; and


• Be accountable for statements made with respect to individuals with disabilities and shall distinguish clearly, where appropriate, statements and actions made as an individual and those made as a representative of DDAWNY.

Consent

AUTHORIZATION OF CHIEF EXECUTIVE OFFICER

I have received and reviewed the Developmental Disabilities Alliance of Western New York’s By-Laws and Mission Statement included in this application and hereby submit an application for membership.

Signature

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