CAC Membership Application

Center for Persons with Disabilities
Utah State University
Consumer Advisory Council
Application Form

The Center for Persons with Disabilities seeks willing persons with disabilities, their family members, or representatives from community/state agencies who work with people with disabilities to participate on the Consumer Advisory Council (CAC). 

Interested persons should fill out the following form and turn it into the CPD Consumer Liaison, Gordon Richins.  This form can be submitted at any time and will be kept on file for consideration when openings on the CAC become available. Presently there are positions open in these three areas; individual with a developmental disability, family member, state/community agencies.

Date Submitted: ____________________
Name:  ______________________________________________________
Address: _____________________________________________________
City:       _____________________________________________________
Phone: _______________________E-mail Address ________________________

1.)    Please share why you are  interested in serving on the Consumer Advisory Council (use additional page if more space is needed):




 
2.)    Please list any qualifications or experiences that you have had that you feel would benefit the Consumer Advisory Council (Use another page if needed):




 
3.)        Please check the category that would best describe your role on the CAC:
____Individual with disability
____Family member of person with disability
____Representative of state agency/local agency or nonprofit program

Please return this form to: Gordon Richins, Center for Persons with Disabilities,
Utah State University, 6800 Old Main Hill, Logan,UT 84322-6800 or use gordon.richins@usu.edu 


This form is available in alternate
formats upon request.