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* 1. Name

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* 2. Contact Information

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* 3. Occupation

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* 4. Are you a (please check one)

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* 5. If you are a person with a Developmental Disability, or the parent or legal guardian of a person with a Developmental Disability, please indicate the type of disability:

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* 6. How did you develop your interest or knowledge of Developmental Disabilities? Describe your employment, education, or other experiences and activities which demonstrate your interest or knowledge:

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* 7. Do you have any experience or skills in the following?

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* 8. Are you a member in any associations, service clubs, social clubs or professional organizations?  If so, which ones?

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* 9. Have you held office on any other boards?  If yes, which ones?

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* 10. What are your hobbies and/or special interests?

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* 11. Are you currently employed by an organization providing services to people with Developmental Disabilities?  If yes, please explain:

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* 12. Are you the member of the governing board of any organization providing service to people with Developmental Disabilities?  If yes, please explain:

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

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