CRP Membership Application

Thank you for your interest in volunteering to serve on one of California’s Citizen Review Panels. This application should be accompanied by the Membership Application and Selection Process document. Contact Erin Manske, CRP Project Coordinator at emanske@bprac.com with any questions related to these documents. Please complete and return this application to emanske@bprac.com no later than September 12, 2018. All responses will remain confidential.

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* 1. Contact Information

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* 2. Date of Birth

Date / Time

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* 3. Gender (Optional)

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* 4. Ethnic Origin

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* 5. Level of Education

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* 6. Are you willing to serve an initial term of two years on the Panel?

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* 7. Are you able to attend one work day meeting each quarter, if scheduled in advance?

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* 8. Do you currently have any pending or open cases in the child welfare or court systems?

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* 9. Are you or have you ever been a foster parent?

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* 10. Are you an adoptive parent?

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* 11. Have you or has anyone in your family been involved with the child welfare system?

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* 12. If yes, please explain:

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* 13. How did you become aware of the CRP application process?

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* 14. Which panel(s) are you most interested in becoming a member? Panel descriptions can be found in the accompanying document.

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* 15. What are your reasons for wanting to serve on a Panel?

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* 16. Who is your current employer? Describe your position and responsibilities.

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* 17. What, if any, professional training, degrees, certificates and licenses do you hold?

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* 18. In what other organizations, boards, or volunteer activities are you involved?

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* 19. What relevant system experiences do you have that would be beneficial to a panel?

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* 20. How would you describe your ability to work as a team member?

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* 21. Is it more important to listen, be open-minded, and non-judgemental or to provide constructive feedback? Describe how you would balance listening with providing feedback.

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* 22. How would you articulate ideas, concerns, and thoughts to a diverse group of people?

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* 23. In what ways do you demonstrate sensitivity to diversity (cultural, ethnic, economic, mental health, physical disabilities, or others)?

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* 24. What does it mean to you to have a strength-based approach to working with children and families, and how might panels employ a strength-based framework to their activities and recommendations?

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* 25. Do you have any reservations about serving as a Panel member?

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* 26. List any potential conflicts of interest that you may have while serving on the Panel, including but not limited to personal or professional experiences with services provided by CDSS.

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* 27. Reference 1 0f 3

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* 28. Years Known

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* 29. Reference 2 0f 3

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* 30. Years Known

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* 31. Reference 3 0f 3

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* 32. Years Known

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* 33. I understand that to promote the integrity of the citizen review panel, ensure confidentiality is maintained, to protect the safety of the volunteer panel members and those involved with the agencies and cases reviewed, we use many methods of screening, including criminal and child maltreatment records checks.

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* 34. I understand that the information contained in this application will be used to select a panel that is representative of the community.

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* 35. I submit the statements on this application are true, complete and correct to the best of my knowledge.  I understand that falsification on this application can disqualify me from consideration or result in dismissal from a Panel at a future date.

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* 36. Signature

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* 37. Date

Date / Time

T