Fillable LIFEWAYS ADVISORY COUNCILS/COMMITTEES REQUEST FOR APPOINTMENT should complete (Lifeways Community Mental Health)

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LIFEWAYS ADVISORY COUNCILS/COMMITTEES REQUEST FOR APPOINTMENT should complete (Lifeways Community Mental Health)

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LW# 6-01.01-A Page 1 of 2 02/2021
LIFEWAYS ADVISORY COUNCILS/COMMITTEES
REQUEST FOR APPOINTMENT
The LifeWays Board of Directors, following recommendations from the LifeWays Advisory Councils/
Committees, appoints interested citizens to serve on the Advisory Councils/Committees of the Board.
Persons who wish to represent the community and our consumers as an Advisory Council or
Committee member
should complete the following information.
Name:
Address (include street, city, zip code):
Phone (Day): Phone (Evening):
Please indicate your preference to which appointment is requested:
(1 = desired; 2 = will consider; 0 = not interested)
Consumer Advisory Council
Recipient Rights Advisory Committee
Self-Determination Advisory Committee
I am a (please check all that apply):
Consumer or former consumer of services
Family member of current or former consumer
Representative of public interest
Representative of consumer organization(s)/advocacy group(s)
I represent services in the county(ies) of (check all that apply):
Jackson
Hillsdale
I represent the following service populations (check all that apply):
Adults with Mental Illness
Individuals with Developmental Disabilities
Families with children with Serious Emotional Disturbance
Individuals with Substance Use Disorders
I am interested in becoming: Voting Member Non-Voting Member
Please indicate applicable community activities or organizations you are involved in:
Activity/Organization
Positions(s) Held
Length of Time
LW# 6-01.01-A Page 2 of 2 02/2021
Additional information you feel may be helpful to the Advisory Council/Committee and the
LifeWays Board of Directors in considering your appointment request:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Employment (if applicable):
Current Employer: ___________________________________________________________________
Position: _____________________________________________________ Years: ________________
Education (if applicable):
High School: ________________________________________________________________________
College: ____________________________________________________________________________
Other: _____________________________________________________________________________
Please list three references we may contact:
Name
Address
Phone
My signature authorizes my consent to contact the above-named references and signifies my
interest in serving on an Advisory Council/Committee to the LifeWays Board.
_______________________________________________________ _____________________
Signature Date
Please submit completed application to:
Customer Services
LifeWays
1200 N. West Avenue
Jackson, MI 49202
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LIFEWAYS ADVISORY COUNCILSCOMMITTEES REQUEST FOR APPOINTMENT should complete (Lifeways Community Mental Health)

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Completed 5 March 2021

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