Committee Membership Application

I understand that Sandhills Center committee members must live in Anson, Harnett, Hoke, Lee, Montgomery, Moore, Randolph or Richmond counties. Members must have received services OR are family members of those who have received mental health, developmental disabilities and/or substance abuse services from Sandhills Center. Committees strive to be ethnically and culturally diverse. Employees of Sandhills Center, or agencies under the direction of Sandhills Center may not apply.

The confidentiality of persons applying for committee membership will be respected. Information on this application will only be used by the Consumer and Family Advisory Committee (CFAC) to choose its members based on State requirements for diverse and balanced representation OR by Sandhills Center staff for the selection of members for other committees.

I am interested in serving on the committee(s) checked below.

Consumer and Family Advisory Committee____ Client Rights Committee_____

Workgroups_____ Request for Proposal Review Teams_____ Focus Groups_______

I am male____ female______

I am Caucasian____ African American______ Hispanic/Latino_____ Asian_____

Native American_____ Other_____

I received services for: substance abuse____ mental health issue_____

a developmental disabilities/traumatic brain injury_____. Year(s)__________________

I am a family member of an ____adult or ____child who received services for:

___substance abuse ___mental health issue ___a developmental disability/traumatic brain injury

NAME_________________________________________________________________________________

ADDRESS_____________________________________________________________________________

CITY_________________________________________________ZIP______________________________

PHONE__________________________________________ FAX_________________________________

EMAIL________________________________________________________________________________

RELATED EXPERIENCE_________________________________________________________________

_____________________________________________________________________________________

I WANT TO SERVE ON THIS COMMITTEE BECAUSE_________________________________________

_____________________________________________________________________________________

___________________________________________________TODAY’S DATE_____________________

MAIL THIS FORM TO:

Mike Markoff , Consumer Affairs & Customer Services Director

Sandhills Center

P.O. Box 9

West End, NC 27376

OR EMAIL TO: mikem@sandhillscenter.org