Thank you for your interest in the System of Care Advisory Council (SOCAC). As we welcome you into this work, it's helpful to know a little bit about you and why you want to get involved. Please only share what you feel comfortable with; inclusion in this work is not dependent on the information you provide. Information shared will be reviewed by SOCAC staff and members of the Diversity, Equity and Inclusion Committee. If you need assistance completing this form or would like to share this information in another format, please email statewide.soc@oha.oregon.gov.

Before completing this form, please ensure you meet the following criteria:

· You live or work in Oregon, AND have reviewed the SOC website

AND

· As a family member, you have a child who is currently or has been involved in two or more systems,
OR
· As a youth member, you are between the ages of 14-26 years old and have been involved in two or more systems,
OR
· You work for a child or family serving agency or organization.

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* 1. What is your (preferred) name?

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* 2. What is your email?

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* 3. What is your phone number?

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* 4. What is the best way to contact you?

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* 5. What county do you live in?

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* 6. Are you engaging with SOCAC as a representative of your employer?

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* 7. If so, who is your employer?

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* 8. What experiences, professional and/or personal, are you bringing to this work? This question helps ensure people with lived experience are represented.

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* 9. Please speak to how your background has shaped your experiences. You might consider things like disability, race, culture, gender identity, sexual orientation, socioeconomic status, geography, urban/rural, farming, military, etc. This is not an exhaustive list. This question helps us understand the variety of perspectives and experiences in our work.

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* 10. What are your reasons for wanting to join the SOCAC? This question helps ensure your interest aligns with SOCAC values and priorities.

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* 11. Is there anything else you want to share? This question helps to ensure we didn't miss anything in this form.

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* 12. As most SOCAC meetings are conducted online, a phone, laptop or tablet, and connection to WiFi are needed to meaningfully participate. Do you have access to these things?

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* 13. If you answered no to question 11, please explain. SOCAC staff are happy to talk with you about equipment and technology access.

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* 14. What additional support or accommodations can we provide to assure you can fully engage in the SOCAC?

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