2018 CCAEJ Boards & Commissions Training Application
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First Name *
Last Name *
Organization *
Title
Street Address *
City *
Zip Code *
Phone Number *
Which city council district do you live in? *
Who is your current city council representative? *
Which county district do you live in? *
Who is your current county supervisor? *
Have you ever served on a board or commission? If yes, please list. *
Have you or are you interested in pursuing elected office? *
In order to ensure that all Fellows have a certain level of knowledge and skills to be an effective advocate commissioner once placed, we require participants to attend ALL of the meetings. Please confirm that you are able to attend all sessions of the 2018 training. *
If no, please list the dates you are unable to attend. *
The goal of the program is to get equity leaders placed on a board or commission. We are asking for commitment to apply to board or commission within at least six months completion of the training. *
If no, please explain. *
Please send a PDF of your resume to josephine.y@ccaej.org. *
Required
Short Answer Questions
Tell us more about yourself and your interest in serving on a commission in the following questions.
What is the change you envision for your community and how does serving on your commission of interest help to move you closer to that change? *
Who do you consider to be your community? Once placed on a commission, how do you plan to hold yourself accountable to that community? *
Questions or concerns?
Emergency Contact Information
Name (First & Last) *
Relationship *
Phone Number *
Additional Information
Please list any constraints that may prevent you from attending any of the sessions. (Example: childcare, health) *
Do you have any dietary preferences or other accommodations? If so, please state. *
I give consent to the Center for Community Action and Environmental Justice (CCAEJ) to photograph me to educate others about the programs and services offered by CCAEJ. Possible uses include: illustration of articles in newsletters, in profiles that contributors receive, in brochures, to illustrate services discussed on the web site, in displays at community fairs, to publicize local programs, to make professional presentations, to conduct research on teaching techniques and equipment used, and to publicize the program. In giving approval, I understand it is without consideration of compensation of any kind, and CCAEJ is released from any claims or liability. *
I understand that in the event of a medical emergency, CCAEJ will not make any medical decisions regarding myself. I understand that CCAEJ staff will contact the emergency contacts provided above before authorizing medical professionals to attend, transport, and treat myself. I agree to assume financial responsibility for all expenses for such care. *
My electronic signature certifies that all of the information above is correct to the best of my knowledge. *
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