Application for Steering Committee on Reduction of African American Child Deaths This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.Your Contact InformationYour Name(Required) First Last Your Email Address(Required) Email Address Confirm Email Address Your Phone Number(Required)Alternate Phone NumberQualifying County InformationSteering Committee Members must live or work in Sacramento County.(Required) Yes, I live in Sacramento County. Yes, I work in Sacramento County. No, I do not live or work in Sacramento County. Work Address Street Address Address Line 2 City ZIP Code Residence Address Street Address Address Line 2 City ZIP Code Supervisorial District InformationSacramento Supervisorial District in which you live or work(Required)If you do not know the supervisorial district in which you live, contact the County Clerk’s office at 874-5411.Do you live or work in an incorporated city?(Required) Yes, I live or work in an incorporated city. No, I do not live or work in an incorporated city. If yes, which incorporated city?Areas of RepresentationPlease indicate the seat that you are applying to fill.(Required) Department of Child, Family and Adult Services Department of Human Assistance County Public Health Officer First 5 Sacramento Commission Child Abuse Prevention Council Foundations Healthcare Systems (please indicate below what healthcare system) Community-Based Health Provider Judicial Education Workforce Development Housing Advocacy and Policy Civic Groups Faith-Based Organizations Parent Representative Youth Representatives (up to age 25) Advocates Maternal Child and Adolescent Health Board Law Enforcement Child Protective Services Department of Health Services Behavioral and Mental Health Domestic Violence Service Provider Department of Health Services Select your top choice from the list above of Steering Committee seats.Please indicate whether your experience with regards to the above selection is personal or professional.(Required) Personal Professional Please check additional seats that you are willing to apply for.(Required) Department of Child, Family and Adult Services Department of Human Assistance County Public Health Officer First 5 Sacramento Commission Child Abuse Prevention Council Foundations Healthcare Systems (please indicate below what healthcare system) Community-Based Health Provider Judicial Education Workforce Development Housing Advocacy and Policy Civic Groups Faith-Based Organizations Parent Representative Youth Representatives (up to age 25) Advocates Maternal Child and Adolescent Health Board Law Enforcement Child Protective Services Department of Health Services Behavioral and Mental Health Domestic Violence Service Provider Department of Health Services ExperienceIn providing the following information, identify the manner and extent of your experiences. As applicable, provide any specific experience you may have related to reducing disparities and/or improving outcomes for African Americans. Attach additional pages if needed. A resume may be attached containing this and any other information that would be helpful in evaluating your application.Attach your resume here Drop files here or Select files Max. file size: 300 MB. EDUCATION(Required)EMPLOYMENT EXPERIENCE(Required)COMMUNITY EXPERIENCE, AFFLIATIONS AND AWARDS(Required)BOARDS, COMMISSIONS, COMMITTEES ON WHICH YOU HAVE SERVED(Required)OTHER EXPERIENCES YOU FEEL WOULD BE HELPFUL IN MAKING THIS APPOINTMENT(Required)WHAT GOALS DO YOU HAVE IN SERVING ON THE STEERING COMMITEE(Required)Do you or any member of your immediate family work for the County of Sacramento or hold a position that might conflict with your ability to make impartial recommendations?(Required) Yes* No *If you answered yes above, please tell us more.ReferencesPlease provide THREE references with email and telephone numbers.(Required)
