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2. First Name*
3. Last Name*
5. Primary Phone Number*
6. Email*
8. Address*
9. City*
11. Zip*
13. Why do you want to be a part of the 708 Community Mental Health Board in Vernon Township?*

    In 500 words or less, please summarize your personal interest in the subject matter of the 708 Board (Mental Health/Substance Use Disorder/ Intellectual/Developmental Disability) as well as your community involvement, including current volunteer/board roles as well as previous roles that may have relevance.  

15. What qualities, experiences, and/or skills would you bring to your board membership?*
17. Optional: Share a goal that you envision for the Vernon Township 708 Community Mental Health Board
19. Potential Conflicts of Interest*

    Please disclose any affiliation or involvement - personally or professionally - with any organization that might benefit from your membership on this board.  This disclosure will not necessarily preclude your selection.  All board members will be required to sign an annual conflict of interest statement and recuse themselves from any board activity when necessary.  

21. Resume*

    Please upload your resume to complete your application.

    Once submitted, a member of the selection committee will be in touch with you soon.  

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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

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