MHSA Steering Committee - New Member Application

Applicant Information

Please complete this application if you are interested in serving on the MHSA Steering Committee. Applications are reviewed in May and October of each year. For more information about MHSA and the MHSA Steering Committee Roles and Responsibilities, including current membership composition and past meeting materials, visit the MHSA website, under the "Steering Committee" tab. If you would prefer the application emailed or mailed to you, send a request to MHSA@smcgov.org.

Question Title

* 1. Please provide your name and email.

First Name:

Last Name:

Email:

Question Title

* 2. Are you a member of any relevant groups (commission, committee, advocacy group, collaborative, etc.)?

Yes. Please list all behavioral health-related groups you are affiliated with, that you would like represented:

Question Title

* 3. Are you applying as an employee or board member of an organization/agency?

Yes. Please list the organization(s) you are representing and your title/role at each: