APPLICATION FOR THE NETWORK AND PLANNING ADVISORY COMMITTEES
Network Management – Planning and Authority Certification
4402 Vance Jackson, Suite 102, San Antonio, Texas 78228
Phone: 377-0741
Fax: 377-2283
TITLE: [] MR. [] MRS. [] MISS [] MS. [] DR. [] REV
Today’s Date: _________________
LAST NAME ____________________________ FIRST NAME__________________ MI ______
HOME ADDRESS: ______________________________________________
ZIP CODE __________
SSN: ______-_____-______ DATE OF BIRTH: ____/_____/____
GENDER: [] MALE [] FEMALE
Home Phone: _________________Work Phone: _________________
E-mail Address ___________________ Driver License # ______________________
Which Committee are you applying for?
[] Network Advisory Committee [] Mental Health Planning Advisory Committee
[] Substance Abuse Advisory Committee [] Children’s Advisory Committee
[] Mental Retardation Advisory Committee
Do you consider yourself?
[] Consumer [] Family member, not consumer [] Advocate, not family member or consumer
What do you consider yourself?
[] Latin/Hispanic [] Anglo [] Black [] Asian Pacific Islander [] Native American [] Alaskan Native
Do you speak?
[] English [] Spanish [] American Sign [] other languages
(please specify) __________________________
Do you have experience in any of the following areas? (Please indicate years of experience)
Area Years of Experience
[] Mental health treatment and issues _________________
[] Mental retardation treatment and issues _________________
[] Substance abuse and use treatment and issues _________________
[] Child mental health treatment and issues _________________
[] Health Care planning _________________
[] Participation on advisory committees _________________
[] Participation in strategic planning _________________
[] Working knowledge of financial planning _________________
Do you have experience in any of the following areas? (Please indicate years of experience)
Area Years of Experience
[] Participation in contract management _________________
[] Development of RFI, RFA, and RFP’s _________________
[] Other Experience (Please Specify) _________________
Are you related to a member of the Center’s Board of Trustees? [] Yes [] No
How would you describe your membership on this committee?
[] A provider with a current contract with the Center
[] A provider with a pending or potential contract with the center
[] Representing NAMI San Antonio
[] Representing NAMI San Antonio South
[] Representing ARC
[] Representing a private hospital organization
[] Business sector
[] Self, not representing or affiliated with any organization
[] Other (Please specify)
Briefly describe why you want to serve on one of these advisory committees and how would the consumers, family members and stakeholders of the Center benefit from your appointment.
I understand that membership on an Advisory Committee will require a commitment on my part to complete required member training, attend committee meetings, complete committee work assignments on time, and bring the best of my capabilities to studying and understanding the issues presented before the Committee.
The contributions Advisory Committee Members make will have significant implications for the current and future business of The Center for Health Care Services and services to the citizens of Bexar County. This is a responsibility I promise to uphold. I further understand that my signature authorizes the Center to use my name to conduct a criminal conviction check through the Texas Department of Public Safety and/or the FBI.
Signature: ________________________________ Date: ______________________
