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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.
1.Name:(Required.)
2.Do you currently reside in the state of California?(Required.)
3.Address:
4.Phone number (please include area code):(Required.)
5.E-mail address:(Required.)
6.What best describes your gender identity?(Required.)
7.Identify which geographic area(s) you live, or if you represent an organization or association, you primarily serve (select all that apply):(Required.)
8.Racial/Ethnic background:(Required.)
9.Occupation (if applicable):
10.As a member, I would represent (select one):(Required.)
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):(Required.)
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.(Required.)
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.(Required.)
14.What are the central issues related to Alzheimer’s and other dementias you would recommend the committee consider and why?(Required.)
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?(Required.)
16.Electronic signature is acceptable. Signature of the person completing this form. **Typing in your full name below is considered equivalent to a signature.