Please enable JavaScript in your browser to complete this form.Name *FirstLastFamily Member (please check all those that apply):biologicaladoptivefostergrandparentotherIf other please specify the relationship:AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeHome PhoneWork PhoneCell PhoneBest number to contact you:Home PhoneWork PhoneCell PhoneBest time of day to contact you:Email *Are you aboriginal or other minority (voluntary self-identified)?YesNoNumber 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?YesNoWhich 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 NameSubmit