Missouri Parents Act (MPACT) Board of Directors Application

MPACT is a Missouri statewide, non-profit parent training information center.

The IDEA requires that the Parent Training Information Center (PTI) must be a parent-led organization that has a Board of directors, the majority of which must consist of parents of children with disabilities from birth to age 26 with disabilities. The Board must also include individuals with disabilities and individuals working in the fields of special education, related services, and/ or early intervention. The parent and professional members of the Board must be broadly representative of the population to be served (Missouri resident), including low-income parents and parents of English learners.

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* 1. Contact Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Please describe your past and present experiences and expertise you believe are relevant or helpful to serving as a member of the MPACT Board of Directors:

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* 3. Why are you interested in serving on this board?

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* 4. Have you had contact with MPACT before (received assistance, attended training, made a donation, or volunteered)? If so, please describe that experience:

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* 5. Do you have previous Board experience? If so, please describe that experience (types of projects, executive positions, accomplishments, teamwork, or unique skills):

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* 6. Please list other Boards that you have served on past in the past or serve on now (including periods of service):

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* 7. Do you have previous business or professional experience you believe would be useful to the MPACT Board? Describe that experience (include items such as education, advocacy, fundraising, etc.):

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* 8. Do you have volunteer community service experience? Please describe that experience, going back as far into your history as you think is helpful:

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* 9. What other organizations, parent support groups or advisory committees do you support (with either time, money, or otherwise)?

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* 10. How can you help MPACT to make a difference in the community?

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* 11. Do you feel that you will be able to meet MPACT’s board member time commitments? These are described in the MPACT Board Member Fact Sheet, see link at the beginning of this application.

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* 12. What expectations do you have of MPACT and your service to this organization?

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* 13. Will you be willing to commit financially to MPACT?

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* 14. Are you a parent of a child with a disability:

Yes

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* 15. Ages of Children?

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* 16. Are you a person with a disability:

Yes

Please list 2-3 references:

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* 17. Reference:

Name:

Phone Number:

Years Known:

Relationship:

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* 18. Reference:

Name:

Phone Number:

Years Known:

Relationship:

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* 19. Reference:

Name:

Phone Number:

Years Known:

Relationship:

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* 20. If you are a current board member or a community member nominating this person as an MPACT Board Member please describe the special reasons for your consideration:

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* 21. Recommended By:

Contact Information for Person providing recommendation (if any):

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* 22. Home Phone #s:

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* 23. Cell:

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* 24. Email:

MPACT Governance Committee
1530 S Main St. Ste. 4
Joplin, MO 64801

Email: info@missouriparentsact.org
Phone: 1-800-743-7634
Fax: 636.387.6296

Empowering families to advocate for themselves so that children with special educational needs can reach their full potential in education and life – through support, training and education