Families and Communities United

A Family's Journey

Training Opportunities

Join the FCU

Youth Advisory Board

Pennsylvania
Child Welfare
Resource Center

Family Group
Decision Making

Newsletters

The following questions ask for personal information. It is important we select Committee Members who represent the diversity of Pennsylvania as well as those who have an understanding of our formal systems. This information is confidential and will not be shared with anyone except the selection committee. If you need extra space to answer any of the questions, feel free to use a separate piece of paper. Thank you for your interest.

Name:

This is required.

Street Address:

City: State: Zip Code:

E-mail address:

Please enter a valid email address.

Daytime telephone number:

Evening or cell telephone number:

Best time to call: AM PM

What Systems are you involved in? Check all that apply:

Children & Youth MH/MR Juvenile Probation Drug and Alcohol
Community Service Other: Please Explain:

Type of Involvement: If Other selected, please explain:

What county were/are you involved with?

Date case closed (if applicable)

(Children and Youth cases must be closed at least one year from date of application)

Tell us about some of your experiences dealing with Family serving system/systems? (i.e. education, child welfare, juvenile justice etc.). Again, this information will be kept confidential.

What changes would you like to see in family serving systems?

What can you do to be a part of those changes?

REFERENCES:
Please list the names, complete addresses (including zip code), email address and daytime phone numbers of 3 non-relative references.

REFERENCE #1

Name:

Address:

Daytime Phone:

Email:

Relationship:

REFERENCE #2

Name:

Address:

Daytime Phone:

Email:

Relationship:

REFERENCE #3

Name:

Address:

Daytime Phone:

Email:

Relationship:

Signature: Date: