Date:

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* 1. Date:

Date / Time
Name:

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* 2. Name:

Address:

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* 3. Address:

City:

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* 4. City:

State:

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* 5. State:

Zip:

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* 6. Zip:

Home Phone:

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* 7. Home Phone:

Cell Phone

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* 8. Cell Phone

Work Phone: 

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* 9. Work Phone: 

Is it okay to call you at work?

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* 10. Is it okay to call you at work?

Email Address:

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* 11. Email Address:

Applicant Birthday (Month/Day only):

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* 12. Applicant Birthday (Month/Day only):

Primary Language Spoken:

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* 14. Primary Language Spoken:

Mark your area(s) of interest: 

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* 16. Mark your area(s) of interest: 

Mark your Region (see insert)

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* 17. Mark your Region (see insert)

What County are you located in?

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* 18. What County are you located in?

What is your current role?

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* 19. What is your current role?

Why would you like to serve on the Parent Advisory Board?

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* 20. Why would you like to serve on the Parent Advisory Board?

How would you identify your primary system involvement?

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* 21. How would you identify your primary system involvement?

Parent Advisory Board Members should reflect the families represented in the following systems: Mental Health, Education, Child Welfare and Juvenile Justice. Please share how you have been involved as a parent/caretaker of a child whose emotional and/or behavioral challenges required accessing resources, supports and services from multiple child-serving agencies.

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* 22. Parent Advisory Board Members should reflect the families represented in the following systems: Mental Health, Education, Child Welfare and Juvenile Justice. Please share how you have been involved as a parent/caretaker of a child whose emotional and/or behavioral challenges required accessing resources, supports and services from multiple child-serving agencies.

I understand that completion of this application does not bind the applicant or the Parent Advisory Board in any way. The PAB reserves the right to choose participants that best meets the need of the program. Before participating on the Parent Advisory Board, you will be asked to sign a confidentially agreement.

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* 23. I understand that completion of this application does not bind the applicant or the Parent Advisory Board in any way. The PAB reserves the right to choose participants that best meets the need of the program. Before participating on the Parent Advisory Board, you will be asked to sign a confidentially agreement.

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