CFAC Membership Application **** All information in this section marked with an asterisk is REQUIRED **** General InformationName* Home Address* County*Please select one ...AlamanceAlexanderAlleghanyAsheAveryBuncombeCaldwellCaswellChathamCherokeeClayFranklinGrahamGranvilleHaywoodHendersonJacksonMaconMadisonMcDowellMitchellPersonPolkRowanStokesSwainTransylvaniaVanceWataugaWilkesYanceyCity* State* Zip Code* Home Phone*Work PhoneFaxEmail Address* **** All requested information below this point is REQUIRED **** Membership Requirements It is important that the membership of the Consumer/Family Advisory Committee be representative of all people in our community. Providing this information helps us to make sure this happens. Please check the areas that describe you. Service Represented*Please select one ...Mental HealthIntellectual/Developmental DisabilitySubstance Use DisorderGenderPlease select one ...MaleFemaleOther or prefer not to shareEthnic Group (Check all that apply)* Caucasian African American Native American Asian Hispanic/Latino Other Membership Category*Please select one ...Adult ConsumerYouth Consumer (Under 18)Family MemberIf you have selected Family Member as your Membership Category, please indicate your relationship to the consumer and whether the consumer is an Adult or Youth (under 18).Relationship to Consumer* Relationship to Consumer* Represent Adult Consumer Represent Youth Consumer (under 18) Additional Information The Vaya Health CFAC currently meets as outlined on the attached schedule.I am available to meet with the Consumer and Family Advisory Committee on the designated dates and times.* Yes No I have means of transportation.* Yes No I will need assistance with child / adult care.* Yes No I am willing to have my name placed on the CFAC prospective member list.* Yes No Responsibilities Membership on the CFAC requires a significant commitment of time and energy. Participation involves attending monthly meetings and occasional subcommittee meetings. No special knowledge or training is required to serve on the committee, just a desire to improve the system. Additional reading on topics related to mental health, developmental disabilities and substance abuse issues is required. This material will be provided.I am committed to partnering with Vaya Health to ensure high quality services for all consumers of behavioral healthcare services.* Yes No I am committed to attending monthly CFAC meetings lasting from 2 to 3 hours.* Yes No I am committed to reading materials that are provided.* Yes No I understand that attendance to CFAC meetings is mandatory. In the event that I am unable to attend, I am responsible to inform the Chair or the Liaison as soon as possible prior to the meeting.* Yes No I understand that my participation in public activities of the CFAC may identify me as a consumer or a family member of a consumer of Mental Health, Intellectual/Developmental Disabilities and/or Substance Use Disorder services.* Yes No Please share your reasons for wanting to become a CFAC Member* The information on this application will be used by the Consumer and Family Advisory Committee for the selection of its members based on state requirements to maintain a committee representative of consumers and family members of consumers receiving MH/IDD/SAS behavioral healthcare services. The confidentiality of individuals applying for membership will be respected and protected. Δ