Maltby Centre Family Advisory Committee Application

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* 1. First Name:

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* 2. Last Name:

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* 3. Address:

Number/Unit Number:

Street:

City/Town:

Province:

Postal Code:

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* 4. Phone Number:

Primary Phone Number:

Alternate Phone Number (optional):

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* 5. Email:

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

Primary Phone Number

Alternate Phone Number

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

I am able to attend meetings once per month, likely in the early evening, in Kingston, for 2 to 3 hours per month.

I am interested in supporting families, children, and youth to receive the best services possible at Maltby Centre.

I am comfortable voicing my thoughts and opinions in a group setting in a manner that respects the privacy, perspectives, and choices of other group members.

I am able to share my family’s experiences at Maltby Centre in order to support other families, or for Maltby Centre to learn and grow from these insights and information.

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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. For any questions about this application, please contact FAC@maltbycentre.ca