2019 Board Application (Confidential)

Board Member Information
Valley Mountain Regional Center
P. O. Box 692290
Stockton, CA 9526

Question Title

* 1. Contact Information

Name

Company Name and Address

Home Address

Occupation

Home City/Town

State/Province

ZIP/Postal Code

Email Address

Cell Phone, Work Phone, and/or Home Phone

Question Title

* 2. Optional

Spouse's Name

Ethnic Background (Optional)

Question Title

* 3. Are you a: (Please check one)

Person with a developmental disability

Parent or legal guardian of a person with a developmental disability

Representative of the general public

Question Title

* 4. If you are a person with a developmental disability or the parent or legal guardian of a person with a developmental disability, please indicate type of disability (e.g., intellectual disability, autism, cerebral palsy, epilepsy, other).

Question Title

* 5. How did you develop your interest in or knowledge of developmental disabilities? (Describe your employment, education or other activities which demonstrate your interest or knowledge)

Question Title

* 6. Do you have any of the following special skills? If so, please check and describe more fully below:

Legal Skills

Public Relations Skills

Management Skills

(Describe)

Question Title

* 7. Membership in associations, service clubs, social clubs, professional organizations:

Question Title

* 8. Offices held:

Question Title

* 9. Membership and offices held on other boards:

Question Title

* 10. Hobbies and special interests:

Question Title

* 11. Are you currently employed by an organization providing service to people with developmental disabilities?

Yes

If yes, please explain

Question Title

* 12. I understand that a background check will be performed if I am chosen as a Valley Mountain Regional Center Board Member.

Yes

Question Title

* 13. I am willing to serve:

Yes

(Required) Please complete a statement saying why you wish to serve on the Board and why you believe you are qualified