Board Member Application

Board Application

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email
Which of the following categories best describes you?*
- Primary Consumer: An individual who has received or is receiving services from the department (MDHHS State Facility), from a community mental health services program or services from the private sector equivalent to those offered by the department or a community mental health services program.
- Family Member: A parent, stepparent, spouse, sibling, child, or grandparent of a primary consumer, or an individual upon whom a primary consumer is dependent for at least 50% of his or her financial support.
- General Public: An individual who demonstrates an interest and a commitment to Gogebic Mental Health Authority, who does not have to be a member of a particular organization.
Briefly explain why you are interested in becoming a member of the Gogebic Community Mental Health Authority Board of Directors:ed
Please list any special experience, resources, and/or knowledge you will bring to the Board:
Do you need any special accommodation to assist you in serving on the Community Mental Health Authority Board of Directors? (Please explain)
I understand that this application will be shared with the Gogebic County Commissioners to review and that the information necessary for the appointment will not be made public. I further agree, if appointed, to permit my name to be added to the Gogebic Community Mental Health Board of Directors list. I understand that this list is available to any individual upon request but that it will not include any confidential information.*
- I understand that checking this box constitutes a legal signature confirming all information provided on this application is true and accurate