NC Stakeholder Engagement Group Membership Interest Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The NC Stakeholder Engagement Group (NC SEG) is a cross-disability advocacy initiative focusing on shaping the long-term support and service systems through meaningful engagement and dialogue with policymakers. We are currently the only group in North Carolina that consists solely of individuals receiving services and their family members. We are called "cross-disability" because we represent individuals with developmental disabilities, mental health, substance use disorders, physical disabilities, and family caregivers. Our members come from all areas of the state.

Members meet approximately six times a year in Raleigh, NC to shape the long-term support and service systems through meaningful engagement and dialogue with policymakers. The cost of travel is reimbursed through funding from the NC Council on Developmental Disabilities.

If you are interested in becoming a NC SEG member, please complete the form below. To find you more about the NC SEG, visit our website, www.ncseg.com!

Name

E-Mail Address

Phone Number

What is the best number to reach you at?

City where you reside

You are a...

individual who receives services/eligible to receive services

Family member

Clear selection

Population you/your family affiliate yourself with, in regards to your potential SEG membership... *

Mental Health

Substance Use Disorder

Intellectual/Developmental Disabilities

Traumatic Brain Injury

Physical Disability

Are you able to attend day-long meetings in Raleigh, approximately 6-8 times/year?

Yes

Clear selection

Why are you interested in becoming an NC SEG member?

Are you currently involved in advocacy? If so, tell us how?

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms