Fillable LIFEWAYS ADVISORY COUNCILS REQUEST FOR APPOINTMENT The LifeWays (Lifeways Community Mental Health)

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LIFEWAYS ADVISORY COUNCILS REQUEST FOR APPOINTMENT The LifeWays (Lifeways Community Mental Health)

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LIFEWAYS ADVISORY COUNCILS
REQUEST FOR APPOINTMENT
LW/#223-1 Revised 1/14
The LifeWays Board of Directors, following recommendations from the LifeWays Advisory Councils,
appoints interested citizens to serve on the Advisory Councils of the Board. Persons who wish to
represent the community and our consumers as an Advisory Council 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).
MI/DD Advisory Council
Advisory Council for Recipient Rights
Mid-State Health Network Consumer Advisory Council
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
1. _____________________________
2. _____________________________
3. _____________________________
Position(s) Held
________________
________________
________________
Length of Time
___________
___________
___________
LIFEWAYS ADVISORY COUNCILS
REQUEST FOR APPOINTMENT
LW/#223-2 Revised 1/14
Additional information you feel may be helpful to the Advisory Council and the
LifeWays Board of Directors in considering your appointment:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Employment (If Applicable)
Current Employer:________________ Position: _________________ Years: ____
Education (If Applicable)
High School:___________________________________________________________
College:_______________________________________________________________
Other:_________________________________________________________________
Please list three (3) references we may contact:
Name
_______________________
_______________________
_______________________
Address
___________________
___________________
___________________
My signature authorizes my consent to contact the above named references and
signifies my interest in serving on an Advisory Council 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 COUNCILS REQUEST FOR APPOINTMENT The LifeWays (Lifeways Community Mental Health)

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Completed 5 March 2021

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