Alzheimer's Disease and Related Conditions Advisory Committee Application

Thank you for your interest in serving on the California Health and Human Services (CalHHS) Agency's Alzheimer's Disease and Related Conditions Advisory Committee (ADRCAC). If you have questions, please contact Engage@aging.ca.gov.

REASONABLE ACCOMMODATIONS: If you require a disability-related accommodation, materials in alternate format or auxiliary aids/services, or translation services to complete this application, please email Engage@aging.ca.gov or call (916) 419-7500.

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* 1. Name:

First

Last

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* 2. Do you currently reside in the state of California?

Yes

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* 3. Address:

Street Address

City

State

ZIP Code

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* 4. Phone number (please include area code):

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* 5. E-mail address:

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* 6. What best describes your gender identity?

Female/ Cis-gender female (gender matches sex assigned at birth)

Male/ Cis-gender male (gender matches sex assigned at birth)

Transgender (gender differs from sex assigned at birth)

Genderqueer non-conforming (behavior or appearance does not align with cultural gender expectations)

Don't know

Prefer not to answer

Other (please comment)

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* 7. Identify which geographic area(s) you live, or if you represent an organization or association, you primarily serve (select all that apply):

North Rural (Butte, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Yuba)

North Central (Alpine, Amador, Calaveras, El Dorado, Napa, Placer, Sacramento, Solano, Sonoma, Yolo)

Bay Area (Alameda, Contra Costa, Marin, San Francisco, San Mateo, Santa Clara)

Central Valley (Fresno, Inyo, Kern, Kings, Madera, Mariposa, Merced, Mono, San Joaquin, Stanislaus, Tuolumne, Tulare)

Los Angeles County

Orange County

San Diego (San Diego, Imperial)

Inland Empire (Riverside, San Bernardino)

Statewide (Services are available to individuals regardless of their geographic location within California)

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* 8. Racial/Ethnic background:

American Indian / Native American / Alaskan Native

Asian / Asian American

Black / African American / African

Hispanic / Latino

Middle Eastern / North African

Native Hawaiian / Pacific Islander

White / Caucasian / European

Mixed Race

Prefer not to answer

Other (specify)

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* 9. Occupation (if applicable):

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* 10. As a member, I would represent (select one):

Self/Individual

Organization / Association

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* 11. Membership Category - Please select the open membership category (or categories) for which you are applying. You may also view the list of open positions on the committee website (select all that apply):

Individual representing families of persons directly affected by Alzheimer’s disease or related conditions.

Individual representing organization providing services to persons living with Alzheimer’s disease or related conditions.

Individual representing first responders (first responder, emergency medical responder (EMRs), emergency medical technician (EMTs), paramedic, law enforcement, and firefighters)

Individual representing primary care physicians

Individual representing faith leaders

Individual representing financial protection advocates

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* 12. Please provide a brief statement of qualifications that highlights the relevant skills and experience you would bring to the Alzheimer’s Disease and Related Conditions Advisory Committee.

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* 13. Briefly describe the interests you will represent and what you hope to contribute by participating on the Alzheimer’s Disease and Related Conditions Advisory Committee.

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* 14. What are the central issues related to Alzheimer’s and other dementias you would recommend the committee consider and why?

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* 15. Committee members are expected to attend and actively engage in four (4) committee meetings per year held virtually and in person at the California Department of Aging office in Sacramento. Meeting dates are posted on the committee website. Committee meetings are four (4) hours in duration and include a lunch period, Committee meetings are open to the public. Will you be able to meet this expectation?

Yes

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* 16. Electronic signature is acceptable. Signature of the person completing this form. **Typing in your full name below is considered equivalent to a signature.