Jefferson County Community Services Board Application

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Name: *

Phone Number: *

Home Address: *

Employer's Address: *

Business Phone Number: *

Email Address: *

Where would you like to be contacted? *

Home

Business

Please indicate which committee(s) you would like to be considered for: *

Full Community Services Board

Mental Health Subcommittee

Persons with Developmental Disabilities Subcommittee

Substance Use Subcommittee

Required

Do you have training, an educational background, or you or a family member have lived experience in the area of MENTAL HEALTH?
*

Yes

If answered YES, how?

Do you have training, an educational background, or you or a family member have lived experience in the area of DEVELOPMENTAL DISABILITIES?
*

Yes

If answered YES, how?

Do you have training, an educational background, or you or a family member have lived experience in the area of SUBSTANCE USE DISORDERS?
*

Yes

If answered YES, how?

Service clubs, social clubs, and professional associations in which you are a member:
*

Volunteer activities in which you have participated:
*

Are you aware of any potential conflicts of interest? If so, how:
*

Please provide a brief statement as to why you would like to be a Board Member for the Community Services Board:
*

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