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PA Families, Inc. looking for board members

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PA Families, Inc. aka PFI is undergoing a significant reorganization and is looking to enhance their Board of Directors. They are looking for diversity and statewide representation of families across the Commonwealth of Pennsylvania. PFI is looking for your help in sending out this application to potential applicants so in moving forward PFI is a strong statewide family network. Following the System of Care philosophy, PFI will be restructuring the organization to further its efforts in supporting families wants and needs across all State child serving systems including but not limited to Mental Health, Child Welfare, Juvenile Justice, Juvenile Probation, Education, Drug and Alcohol, etc. but will also provide Natural Supports for families within their communities.
Below is the application for you to print and return to them:

Pennsylvania Families Incorporated Board of directors Application Form
PA Families, Inc. (PFI) has requested the following personal information about you in order to make decisions regarding your application to become a PFI Board member. It is important that we select board members who are experienced in raising a child or children with mental health or physical health challenges, or who have a personal interest in the child and adolescent systems. This information is confidential and will not be shared with anyone except current PFI Board of Directors. Thank you for your interest In PFI.
Name: ________________________________________________
Mailing Address: ________________________________________________
________________________________________________
________________________________________________
Daytime telephone: ________________________________________________
E-Mail Address: _______________________________________________
1. Do you have a child (or children) with mental health or physical health challenges? Yes No 

2. Do you, a family member, or your children/grandchildren have involvement/issues/knowledge with any of the following? Check all that apply:

Autism Physical Health ADHD
Mental Health Drug and Alcohol Eating Disorders
Intellectual Disabilities Downs Syndrome Anxiety and Panic
Depression/Bi-Polar Disorder Education Legal/Court Systems
Other__________________________________________________________
3. Tell us about your child’s diagnosis, and about your experience with the mental health, physical health, and other child-serving systems (i.e. CYF, Juvenile Justice, Education, Drug & Alcohol etc.):

__________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
4. Have you ever been involved with any parent/family organizations? Please describe:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5. Are you now, or have you ever been involved in any community organizations or committees? Please describe:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
6. Are you now, or have you ever been a member of a board of directors? Please describe:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
7. Why do you want to be a board member of Pennsylvania Families Incorporated?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
8. Do you have any experience working in the following areas? Check all that apply:

Personal Experience Grant Writing Advocacy
Finance Support Groups Mental Health Provider
Marketing/Public Relations Fundraising Healthcare
Health Insurance Education Legal/Court Systems
System of Care

9. Briefly describe your experience and other skills that would benefit this organization:_____________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
10. Please complete the following information about yourself:

a. Community where you live: ____________________________________

b. How would you contribute to the board’s cultural diversity? ________________________________________________________________________________________________________________________________

________________________________________________________________
c. Are you currently employed outside of the home? Yes No 

d. If yes, where do you work, and what do you do? ________________________________________________________________________________________________________________________________

11. How did you hear about this family organization and the opportunity to become

a board member?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________

12. Please list one personal and one professional reference with their daytime

contact information. (The Selection Committee may contact these people)
Name of Professional Reference Phone number or E-mail Address
__________________________ ________________________________
Name of Personal Reference Phone number or E-mail Address
__________________________ ____________________________________
Signature________________________________________ Date: ___________
To be completed by PFI Board of Director member receiving application
------------------------------------------------------------------------------------------------------------
Date Received: ___________ Received by: __________________________

Send application to: Karan A. Steele
karan.steele@valueoptions.com

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