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* 1. First Name:

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* 2. Last Name:

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* 3. Address:

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* 4. Phone Number:

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* 5. Email:

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* 6. What is the best way to reach you?

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* 7. Commitment (please check all that apply):

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* 8. We are hoping to recruit members with diverse perspectives of our services. Please list the services your family has been involved with at Maltby Centre:

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* 9. Why would you like to be a member of the Maltby Centre Family Advisory Committee? 

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* 10. We would like to include diverse perspectives in the activities of the Family Advisory Committee. Are there any perspectives you feel you would bring to the committee? For example: Indigenous, LGBTQ2+, racialized perspective, French language, geographic, ethnic, and personal perspective. 

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* 11. Please describe any skills/characteristics/knowledge/experience/interests you would bring to the committee.

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* 12. Please describe how you would bring your personal or family lived experience with Maltby Centre to inform the work of the Family Advisory Committee. Would you be comfortable sharing your experience with the Family Advisory members.

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* 13. Do you have any concerns around confidentiality or managing conflict or disagreement within a group setting? 

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* 14. Please share any additional comments you may have:

We thank you for your interest in the Family Advisory Committee.  With a limited number of committee membership spaces, not all applicants will be contacted. Your time and interest is greatly appreciated.
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