Citizen Review Panel Application

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* 1. Contact Information

Full Name

Current Occupation & Employer

Mailing Address

County of Residence

City/Town

State/Province

ZIP/Postal Code

Date of Birth

Email Address

Home/Cell and Work Phone numbers

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* 2. Gender

Male

Female

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* 3. Level of Education

Some high school (no diploma/or GED)

GED or High School Diploma

Some College

College Degree

Some Post-Graduate Work

Graduate Degree

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* 4. Ethnic Origin

African American

Asian

Caucasian

Latino/Hispanic

Native American/Native Alaskan

Pacific Islander

Other

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* 5. Are you, or have you been a foster parent?

Presently am

Formerly was

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* 6. Are you an adoptive parent?

Yes

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* 7. Are you able to attend a monthly 2 to 4 hour meeting, if scheduled in advance?

Yes

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* 8. Please indicate which days you are NOT available

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* 9. Are you willing to serve an initial two-year term on panel?

Yes

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* 10. Are you willing to have a Background check?

Yes

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* 11. Please list any experience or knowledge you have had which relates to child welfare (e.g. child advocacy, adoption, abuse & neglect case worker, victim, mental health provider, etc.)

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* 12. What are your reasons for wanting to serve on a Citizen Review Panel to evaluate the child welfare system?

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* 13. In what other organizations, activities, boards or volunteer activities are you involved?

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* 14. List any potential conflicts of interest that you may have while serving on the Citizen Review Panel.

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* 15. List three references (NO RELATIVES). Provide NAME, ADDRESS, PHONE #, and EMAIL.

NAME

ADDRESS

PHONE NUMBER

E-MAIL

--------------------------------

NAME

ADDRESS

PHONE NUMBER

E-MAIL

--------------------------------

NAME

ADDRESS

PHONE NUMBER

E-MAIL

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* 16. I understand that the information contained in this application will be used to select a panel that is representative of the community. I understand the Citizen Review Panel will conduct a criminal history check. I understand my application does not ensure selection to a review panel. I also understand that if selected, I will not be reimbursed for out of pocket expenses incurred while conducting my duties. I further understand that if selected I will be called upon to attend all reviews/meetings of the Citizen Review Panel. I understand that I should expect to meet monthly for two to four hours. Finally, I agree to attend mandatory training/orientation as established by the Citizen Review Panel.

Yes

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* 17. I agree to keep confidential ALL information reviewed by the panel, its actions and its recommendations and to not use any information I obtained from the work of the Citizen Review Panel.

Citizen Review Panel Application

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* 1. Contact Information

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* 2. Gender

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* 3. Level of Education

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* 4. Ethnic Origin

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* 5. Are you, or have you been a foster parent?

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* 6. Are you an adoptive parent?

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* 7. Are you able to attend a monthly 2 to 4 hour meeting, if scheduled in advance?

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* 8. Please indicate which days you are NOT available

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* 9. Are you willing to serve an initial two-year term on panel?

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* 10. Are you willing to have a Background check?

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* 11. Please list any experience or knowledge you have had which relates to child welfare (e.g. child advocacy, adoption, abuse & neglect case worker, victim, mental health provider, etc.)

Question Title

* 12. What are your reasons for wanting to serve on a Citizen Review Panel to evaluate the child welfare system?

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* 13. In what other organizations, activities, boards or volunteer activities are you involved?

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* 14. List any potential conflicts of interest that you may have while serving on the Citizen Review Panel.

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* 15. List three references (NO RELATIVES). Provide NAME, ADDRESS, PHONE #, and EMAIL.

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* 17. I agree to keep confidential ALL information reviewed by the panel, its actions and its recommendations and to not use any information I obtained from the work of the Citizen Review Panel.

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* 18. Signature

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* 19. Date