{"id":3177,"date":"2016-08-02T13:07:39","date_gmt":"2016-08-02T17:07:39","guid":{"rendered":"http:\/\/vayahealth.com\/?page_id=3177"},"modified":"2025-01-20T11:48:43","modified_gmt":"2025-01-20T16:48:43","slug":"cfac-membership-application","status":"publish","type":"page","link":"https:\/\/www.vayahealth.com\/es\/about\/committees\/cfac\/cfac-membership-application\/","title":{"rendered":"Solicitud de adhesi\u00f3n a la CFAC"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_30' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_30'  action='\/es\/wp-json\/wp\/v2\/pages\/3177' data-formid='30' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_30' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_30_13\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Thank you for your interest in joining the Vaya Health Consumer and Family Advisory Committee (CFAC). The CFAC represents and gives voice to people who receive services for mental health, substance use disorder, intellectual\/developmental disabilities (I\/DD), or traumatic brain injury (TBI) by providing important input into Vaya\u2019s operations and processes.<\/p>\n\n<p>A Vaya representative will contact you to follow up on your application. For help, email <a href=\"mailto:cfac@vayahealth.com\">cfac@vayahealth.com<\/a> or call <a href=\"tel:1-800-893-6246\">1-800-893-6246<\/a> and ask to speak with a CFAC liaison.<\/p><\/div><div id=\"field_30_48\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">General Information<\/h3><\/div><div id=\"field_30_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_1'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_30_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_30_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_3'>Home Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_30_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_30_4\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_4'>County of Residence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_30_4' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' >Please select one ...<\/option><option value='Alamance' >Alamance<\/option><option value='Alexander' >Alexander<\/option><option value='Alleghany' >Alleghany<\/option><option value='Ashe' >Ashe<\/option><option value='Avery' >Avery<\/option><option value='Buncombe' >Buncombe<\/option><option value='Caldwell' >Caldwell<\/option><option value='Caswell' >Caswell<\/option><option value='Chatham' >Chatham<\/option><option value='Cherokee' >Cherokee<\/option><option value='Clay' >Clay<\/option><option value='Franklin' >Franklin<\/option><option value='Graham' >Graham<\/option><option value='Granville' >Granville<\/option><option value='Haywood' >Haywood<\/option><option value='Henderson' >Henderson<\/option><option value='Jackson' >Jackson<\/option><option value='Macon' >Macon<\/option><option value='Madison' >Madison<\/option><option value='McDowell' >McDowell<\/option><option value='Mitchell' >Mitchell<\/option><option value='Person' >Person<\/option><option value='Polk' >Polk<\/option><option value='Rockingham' >Rockingham<\/option><option value='Rowan' >Rowan<\/option><option value='Stokes' >Stokes<\/option><option value='Swain' >Swain<\/option><option value='Transylvania' >Transylvania<\/option><option value='Vance' >Vance<\/option><option value='Watauga' >Watauga<\/option><option value='Wilkes' >Wilkes<\/option><option value='Yancey' >Yancey<\/option><\/select><\/div><\/div><div id=\"field_30_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_5'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_30_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_30_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_6'>State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_30_6' type='text' value='' class='small' maxlength='2'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_30_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_7'>Zip Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_30_7' type='text' value='' class='medium' maxlength='10'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_30_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_8'>Primary Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_30_8' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_30_11\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_11'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_11' id='input_30_11' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_30_49\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Demographic Information<\/h3><\/div><div id=\"field_30_12\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Vaya strives to make sure CFAC members are representative of people we serve in our region. Please provide the following information about yourself.<\/p>\n<\/div><fieldset id=\"field_30_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type of Experience (Check all that apply)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_30_42'><div class='gchoice gchoice_30_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='I have experience with mental health, substance use disorder, I\/DD, and\/or TBI needs.'  id='choice_30_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_42_1' id='label_30_42_1' class='gform-field-label gform-field-label--type-inline'>I have experience with mental health, substance use disorder, I\/DD, and\/or TBI needs.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_42_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.2' type='checkbox'  value='I have been a caregiver for a person with mental health, substance use disorder, I\/DD, and\/or TBI needs.'  id='choice_30_42_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_42_2' id='label_30_42_2' class='gform-field-label gform-field-label--type-inline'>I have been a caregiver for a person with mental health, substance use disorder, I\/DD, and\/or TBI needs.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_30_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Area(s) of Lived\/Caregiving Experience (Check all that apply)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_30_43'><div class='gchoice gchoice_30_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Mental health'  id='choice_30_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_43_1' id='label_30_43_1' class='gform-field-label gform-field-label--type-inline'>Mental health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='Substance use disorder'  id='choice_30_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_43_2' id='label_30_43_2' class='gform-field-label gform-field-label--type-inline'>Substance use disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_43_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.3' type='checkbox'  value='I\/DD'  id='choice_30_43_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_43_3' id='label_30_43_3' class='gform-field-label gform-field-label--type-inline'>I\/DD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_43_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.4' type='checkbox'  value='TBI'  id='choice_30_43_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_43_4' id='label_30_43_4' class='gform-field-label gform-field-label--type-inline'>TBI<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_30_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_38'>Gender<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_30_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_30_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_39'>Preferred Pronouns<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_30_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_30_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Race\/Ethnicity (Check all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_30_44'><div class='gchoice gchoice_30_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='American Indian or Alaska Native'  id='choice_30_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_44_1' id='label_30_44_1' class='gform-field-label gform-field-label--type-inline'>American Indian or Alaska Native<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='Asian'  id='choice_30_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_44_2' id='label_30_44_2' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_44_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.3' type='checkbox'  value='Black or African American'  id='choice_30_44_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_44_3' id='label_30_44_3' class='gform-field-label gform-field-label--type-inline'>Black or African American<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_44_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.4' type='checkbox'  value='Hispanic or Latino'  id='choice_30_44_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_44_4' id='label_30_44_4' class='gform-field-label gform-field-label--type-inline'>Hispanic or Latino<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_44_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.5' type='checkbox'  value='Middle Eastern or North African'  id='choice_30_44_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_44_5' id='label_30_44_5' class='gform-field-label gform-field-label--type-inline'>Middle Eastern or North African<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_44_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.6' type='checkbox'  value='Native Hawaiian or Pacific Islander'  id='choice_30_44_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_44_6' id='label_30_44_6' class='gform-field-label gform-field-label--type-inline'>Native Hawaiian or Pacific Islander<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_44_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.7' type='checkbox'  value='White'  id='choice_30_44_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_44_7' id='label_30_44_7' class='gform-field-label gform-field-label--type-inline'>White<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_44_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.8' type='checkbox'  value='Some other race'  id='choice_30_44_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_44_8' id='label_30_44_8' class='gform-field-label gform-field-label--type-inline'>Some other race<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_44_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.9' type='checkbox'  value='Prefer not to share'  id='choice_30_44_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_44_9' id='label_30_44_9' class='gform-field-label gform-field-label--type-inline'>Prefer not to share<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_30_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_57'>Other race<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_30_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_30_50\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Responsibilities<\/h3><\/div><div id=\"field_30_21\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>CFAC membership includes attending regular meetings and occasional subcommittee meetings. Meetings are held in a hybrid format, with the option to attend in person or virtually from your home computer, smartphone, or other device, and generally last two to three hours. Upcoming meeting dates and times are available on our <a href=\"https:\/\/www.vayahealth.com\/calendar\/\">Calendar of Events<\/a>.<\/p>\n<p>No special knowledge or training is required to serve on the committee\u2014just a desire to improve services in our local communities.<\/p><\/div><fieldset id=\"field_30_52\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I understand CFAC members must be adults. I am an adult. (Required)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_30_52'><div class='gchoice gchoice_30_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Yes'  id='choice_30_52_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_52_1' id='label_30_52_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='No'  id='choice_30_52_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_52_2' id='label_30_52_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_30_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am committed to partnering with Vaya to strengthen the state\u2019s public system of public health care services.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_30_59'><div class='gchoice gchoice_30_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Yes'  id='choice_30_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_59_1' id='label_30_59_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='No'  id='choice_30_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_59_2' id='label_30_59_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_30_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I understand that attendance at CFAC meetings is mandatory. If I am unable to attend a meeting, I am responsible for informing the chairperson or the Vaya CFAC liaison as soon as possible prior to the meeting.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_30_53'><div class='gchoice gchoice_30_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Yes'  id='choice_30_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_53_1' id='label_30_53_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='No'  id='choice_30_53_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_53_2' id='label_30_53_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_30_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I will need an accommodation (such as an interpreter service, auxiliary aid, or service for a person with a disability) to participate in CFAC meetings. (A need for an accommodation will not negatively affect your application.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_30_54'><div class='gchoice gchoice_30_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Yes'  id='choice_30_54_1'   aria-describedby=\"gfield_description_30_54\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_30_54_1' id='label_30_54_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='No'  id='choice_30_54_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_54_2' id='label_30_54_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_30_54'>If you answer yes, a new text field will open to allow you to add your requested accommodation.<\/div><\/fieldset><div id=\"field_30_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_55'>You selected yes, please describe the accommodation<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_30_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_30_56\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I understand my participation in CFAC activities may identify me as an individual who has experienced (or as the caregiver of an individual who has experienced) mental health, substance use disorder, I\/DD, and\/or TBI needs.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_30_56'><div class='gchoice gchoice_30_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='Yes'  id='choice_30_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_56_1' id='label_30_56_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_30_56_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.2' type='checkbox'  value='No'  id='choice_30_56_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_30_56_2' id='label_30_56_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_30_32\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_30_32'>Please include any other information you would like to share with the committee.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_30_32' class='textarea large'   maxlength='2000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_30_33\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p style=\"padding:10px;color:red;font-size:11px;border:1px solid black;\"> The Vaya Health Consumer and Family Advisory Committee (CFAC) will use the information provided in this application to select committee members based on North Carolina state requirements to maintain a committee representative of individuals and caregivers of individuals receiving mental health, substance use disorder, I\/DD, and\/or TBI services. 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