Fillable The LifeWays Board of Directors, following recommendations from (Lifeways Community Mental Health)

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The LifeWays Board of Directors, following recommendations from (Lifeways Community Mental Health)

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LIFEWAYS ADVISORY COUNCILS/COMMITTEES
REQUEST FOR APPOINTMENT
LW# 6-01.01-A 01/2020
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).
MI/
DD Advisory Council
Advisory Committee 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.
Position(s) Held Length of Time
2.
3.
LIFEWAYS ADVISORY COUNCILS/COMMITTEES
REQUEST FOR APPOINTMENT
LW# 6-01.01-A 01/2020
Additional information you feel may be helpful to the Advisory Council/Committee 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 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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The LifeWays Board of Directors, following recommendations from (Lifeways Community Mental Health)

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Completed 5 March 2021

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