Valley Mountain Regional Center’s Self-Determination Advisory Committee

Self-Determination Committee Application

Interpretation services and/or accommodations can be provided upon request. *State law requires this committee to “reflect the multicultural diversity and geographic profile” of VMRC’s region.

Question Title

* 1. Your Information

Name:

Address*:

Phone Number:

E-mail Address:

Ethnicity (Optional)*:

Question Title

* 2. Please Check

Individual with a Developmental Disability

Family Member

Other (Please explain)

Valley Mountain Regional Center’s Self-Determination Advisory Committee

Self-Determination Committee Application

Question Title

* 1. Your Information

Question Title

* 2. Please Check

Question Title

* 3. Please provide a brief statement explaining your interest in this committee: