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* 1. Please enter Full Name

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* 2. Please enter your home adress

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* 3. Are you an individual receiving services from Caredesign NY, family member or advocate?

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* 4. Why are you interested in participating on the Regional Advocacy Board?

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* 5. What contribution do you think you can make to the group?

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* 6. What Committee's or Advisory Boards have you previously participated in?

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* 7. What outcomes do you hope to see develop from the Advocacy Board?

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* 8. Are you able to commit to attending quarterly meetings?

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* 9. If you are selected for the Board would you be interested in an elected Officer position?

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