Name *

First

Last

Family Member (please check all those that apply):

• biological
• adoptive
• foster
• grandparent
• other

If other please specify the relationship:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Home Phone

Work Phone

Cell Phone

Best number to contact you:

• Home Phone
• Work Phone
• Cell Phone

Best time of day to contact you:

Email *

Are you aboriginal or other minority (voluntary self-identified)?

• Yes
• No

Number of years you have been a family member:

Number of family members with FASD:

Ages of family members with FASD:

Systems you have experience with:

Are you employed within a professional system?

• Yes
• No

Which system?

In what capacity?

FASD groups or organizations that you previously or currently have connections with:

Tell us something about your family:

Tell us why you are interested in being considered for participation on this committee:

Tell us what your experience will bring to this committee and how that experience could make a difference to this committee:

Tell us how participation on this committee might benefit you/your family/the FASD community:

Please provide two references with their phone and email information we can contact:

Criteria points for consideration in selecting committee members:

• Breadth of personal experience with FASD, especially across ages
• Time available for work involved
• Family status
• Connections within and external to FASD community
• Geographical representation if possible
• Gender mix if possible
• Aboriginal representation
• Broad understanding of issues related to FASD across the lifespan in areas of prevention, diagnosis, intervention, services, supports, systems and families
• Experience with different systems that families with FASD interact with
• Experience with individuals with FASD outside own family
• Awareness of cultural issues
• Understanding of the differences between biological, foster, adoptive and extended families and ability to work with all
• Self confidence
• Insightful
• Ability to think long-term and prioritize items for action
• Positive attitude
• Respect for other points of view
• Ability to maintain confidentiality
• Articulate and ability to be an active discussant in, and contributor to, committee work
• Creative thinker and idea generator
• Willingness to work collaboratively and through consensus
• Ability and willingness to be a public voice
• Experience in FASD related work or organizations
• References

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