Child Passenger Safety Advisory Board Member Application
The Wisconsin Child Passenger Safety Board is seeking applications for the following positions: Public Safety- Fire/ EMS/ Law Enforcement, Public Health- Public Health Specialist/ Nurse, Diversity Member.

It is strongly recommended that the applicants review the Advisory Board Operating Guidelines prior to completing this application (safekidswi.org/og)

First Name *
Your answer
Last name *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Organization/ Company *
Your answer
Title/ Position *
Your answer
What County do you work in?
Your answer
Are you a CPS Technician or Instructor? *
Required
If you are selected as a Board member, will you be able to commit to the required time as outlined in the Operating Guidelines (safekidswi.org/og)? *
The mission of the Board is to maintain the quality and integrity of Wisconsin Child Passenger Safety Program. We do this in part by ensuring our Board members are able to utilize their position on the Board to disseminate information through all of their available channels so that all technicians and instructors across Wisconsin have quality materials. Please keep this in mind as you answer the following questions.
Why you would like to become a member of the Board? *
Your answer
Please describe your involvement or interest with child passenger safety as both an individual and or within your organization. *
Your answer
Please include any past and present professional affiliations at the local, state and national level (ex: Safe Kids, AAP, etc.). *
Your answer
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