DISABILITY RIGHTS PENNSYLVANIA
Application for Board of Directors*
Application for Mental Health Advisory Council (MHAC)*
Application for both Board of Directors and MHAC*
*(SeeInstructionsthroughout application for items marked with an Asterisk*)
*This application can be used to apply for the DRP Board of Directors, the Mental Health Advisory Council or both. Please indicate which membership you are applying for by checking one of the boxes above.
Thank you for your interest in DRP and the MHAC, and for taking the time to submit an application for membership. All applications are reviewed by the joint DRP Board/MHAC Nominating Committee for membership eligibility. The Nominating Committee takes into account the current composition of the DRP Board and the MHAC, along with anticipated needs for new members. If the Nominating Committee determines that you are a good fit for the Board or MHAC, you will be contacted for an interview. Please note that not all persons who submit an application for membership are interviewed but you will be contacted either way.
MISSION STATEMENT: Disability Rights Pennsylvania protects and advocates for rights of people with disabilities so that they may live the lives they choose, free from abuse, neglect, discrimination, and segregation.
VISION STATEMENT: A Commonwealth where people of all abilities are equal and free.
- Personal Information
Name______
Address______
City______Zip______County______
Home Phone______Work Phone______Cell Phone______
Email______Fax______
OPTIONAL: Social Media, e.g. Twitter or facebook account:______
Do you currently have a disability?Yes_____ No______
OPTIONAL: If you answered Yes, what is your disability?______
Do you have a mental illness?Yes _____No ______
Are you a family member of a person with a disability? If yes, please select the relationship(s) that apply:
Parent _____ Partner/Spouse _____ Child _____ Sibling _____
OPTIONAL: If you are a parent of a child with a disability, please list your child’s age and disability:
Check all that apply:
Family Member of a person with mental illness ______
Consumer or former consumer of mental health services ______and/or disability services______
Primary Caregiver for minor receiving mental health services______
Attorney with mental health experience and/or knowledge of mental healthlaw ______
Mental healthprovider______
Mental healthprofessional______
Public Person knowledgeable about mental illness______
- Information to Help us Know You- Youcan attach additional pages when completing this section. If you have a resume, please provide it when you submit your application.
Explain your interest and motivation in joining DRP’s Board and/or MHAC.
______
List your relevant skills, training, and qualifications for joining DRP’s Board and/or MHAC.
______
List your Non-Profit Organization Experience. Please includeyour experience(s) with governance of non-profit organizations, including any leadership, committee, fundraising, or policy development experience.
______
List all boards, committees, and councils on which you currentlyserve.
______
List any disability-related advocacy groups on which you serve or have served.
______
List your affiliations with civic groups, corporations or foundations.
______
______
List what you believe to be theTOP THREE disability and/or MH issues in Pennsylvania. Describe your knowledge of issues affecting persons with disabilities and/or a mental health diagnosis.
______
______
Special Interests/Additional Information. Please provide any additional information or special interests that you feel would be helpful to the Nominating Committee. For example, what do you believe you can contribute to the Board, the MHAC, and DRP? This information can include a resume, letter or additional information about your knowledge, background or involvement in mental health and/or disability issues.
______
Please list two references:
- Name:______
Position: ______
Relationship: ______
Phone:______
Email: ______
- Name:______
Position: ______
Relationship: ______
Phone:______
Email: ______
Please describe your connection to DRP and list acquaintances with any DRP staff, Board members or MHAC members.
______
______
- Additional Personal Information
The information below is collected for federal reporting purposes. We also request this information, along with the demographic information in Section I., to assure a diverse and effective board and MHAC membership, and because Federal law (P.L. 99-319) requires the MHAC to include the following representation. Please check all that apply. Your assistance in providing the information is voluntary.
Ethnicity (choose one):
Not Hispanic or Latino
Hispanic or Latino
Decline to Answer
Race (choose one):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Other
Decline to Answer
Gender: ______
Your AGEgroup? 18 & under _____ 18-35 _____ 36-59 _____ 60-& over_____
DRP does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services. DRP is committed to providing an inclusive and welcoming environment for all members of its staff, volunteers, subcontractors, vendors, and clients.
Please return your completed application and any additional documents (e.g. your resume) to:
Robin Rasco, Administrative Assistant
Disability Rights Pennsylvania
1315 Walnut Street, Suite 500
Philadelphia, PA 19107-4705
You can also fax your application materials to Robin at 215-772-3126 or email it to Robin at: .
THANK YOU!!
Approved at 9/16/16 Board of Directors’ Meeting
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