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AAA, PSA 2 - Advisory Council Application Form

Thank you for your interest in serving on the Advisory Council for the Area Agency on Aging, PSA 2. Please answer all questions with as much detail as necessary and provide your information within the following form.

If you have any questions, reach out to Jessica Cornett using the contact information below.

Jessica Cornett, Communications and Training Coordinator
jcornett@info4seniors.org
326-212-4985
1.Please fill out contact information.(Required.)
2.Age(Required.)
3.I am a resident of...(Required.)
4.If applicable, how long have you been a resident of this county?
5.I work in ...(Required.)
6.Occupation(Required.)
7.Employer (Required.)
8.Work Phone
9.Race(Required.)
10.Do you have a disability? (Required.)
11.Do you use or have experience with services funded by the Area Agency on Aging (such as congregate meals, Healthy U workshops, etc.)? (Required.)
12.Are you employed by, or hold financial interest in, an organization, receiving funds from the Area Agency on Aging? (Required.)
13.Please check all that apply to you:(Required.)
14.Please describe your experience working with older adults, elderly services programs, senior centers, etc. (emphasize any leadership/volunteer experience).(Required.)
15.Please list relevant organizations you belong to.(Required.)
16.What are your special interests?(Required.)
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