Are You a Resident of Kalamazoo County? YES NO
Have you had any Diversity, Equity & Inclusion Training? YES NO
Please indicate experience and/or qualifications that would help make you an effective board member for which you have applied:
Certain categories need to be represented on the Environmental Health Advisory Council. Please check categories which apply to you:
Why do you desire to serve on the Environmental Health Advisory Council?
State law prohibits an individual from being appointed to a community mental health board if he/she is a party to a contract with the community mental health services program or administers or benefits financially from such a contract; or (2) serves in a policy-making position with an agency under contract with the community mental health services program. Listed below is a list of agencies that contract with the Kalamazoo County Community Mental Health Authority Board. This list is not all-inclusive.
Do any of these restrictions apply to you? YES NO
Certain categories need to be represented on the Community Mental Health Authority Board. Please check the categories which you believe apply to you:
(defined as an individual who has received or is receiving services from the private sector equivalent to those offered by the Department or a community mental health services program)
(defined as an individual who is currently directly receiving mental health services from the Department of Community Mental Health, a community mental health services program, or a facility or from a provider that is under contract with the Department or a community mental health services program)
(defined as a parent, stepparent, spouse, sibling, child, or grandparent of a primary consumer, or and individual upon whom a primary consumer is dependent for at least 50% of his/her financial support)
If you checked category a, c, d, e or f above, please explain how you represent that category.
What personal or professional experiences have you had with the target populations served by the Community Mental Health Authority Board?
Why do you desire to serve on the Community Mental Health Authority Board?
There is a limit of six "public officials" who can serve on the Community Mental Health Authority Board. "Public officials" are those persons serving in an elected or appointed public office or employed more than 20 hours per week by an agency of federal, state, city or local government. This includes public schools/colleges/universities.
Are you a public official? YES NO
State law provides that a Jury Board shall consist of not more than two members of the same political party. Please identify your political party membership, if any... i.e. democrat, republican, etc.
Please list below any community boards on which you serve; your reasons for wishing to serve on the Jury Board; and any background experience which may be of value if you are appointed to the Jury Board.
The Board of Commissioners desires minority representation on its appointed commissions. You may choose to identify yourself as a minority. Checking "yes" or "no" will neither qualify nor disqualify you for the appointment.
Representative of the minority community? YES NO
On what community board of directors/commissions are you a member?
Please indicate below the background experience you have which will be of value to you if you are appointed. Also indicate any reasons for desiring to serve on this Commission.