Human Rights Committee 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 Human Rights 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 MemberProfessional/Provider StaffOther Community StakeholderIf 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 Human Rights Committee currently meets as listed in the Events Calendar.I have means of transportation.* Yes No I am willing to have my name placed on the Human Rights Committee prospective member list.* Yes No Responsibilities Membership on the Human Rights Committee requires a moderate level commitment of time and energy. Participation involves attending quarterly 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 quarterly Human Rights Committee meetings lasting from 2 to 3 hours.* Yes No I am committed to reading materials that are provided.* Yes No I understand that my participation in public activities of the Human Rights Committee may identify me as a consumer or a family member of a consumer of Mental Health, Intellectual/Developmental Disabilities and/or Substance Abuse services.* Yes No Please share your reasons for wanting to become a Human Rights Committee Member* Δ If you have any questions about the Human Rights Committee or this application, please call 1-800-893-6246 and ask to speak to a Human Rights Committee liaison or email firstname.lastname@example.org.