Name, address and telephone number of individual applying for consideration to serve as regional Family Support Specialist with the Idaho Federation of Families for Children's Mental Health.

Name:

Address:

City:

State: --Select a State-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zipcode:

Telephone:

Fax:

SSN#:

Are you the parent of a child or children with mental, emotional or behavioral disorder? — Yes No

Are you a family member of a child or children with mental, emotional or behavioral disorder? — Yes No

Please indicate any special attributes you possess that would enhance the diversity and efficiency of the Idaho Federation Board of Directors.

Are you currently a member of the Idaho Federation of Families for Children's Mental Health, Inc.? — Yes No Not Sure

Please tell us something about yourself and how you think your involvement on the Board of Directors would help strengthen the organization. Be sure to include any information on your past history of experience, volunteer or board participation.

Focus on those past or present experiences that you think we should consider in making our decision for the slate of officers. We are looking for people who support the Idaho Federation, are family friendly, and are accessible and open to dialogue with all parents, individuals and families, regardless of age, race or culture. We are also interested in peoples who are assertive and willing to get involved, and committed to improving services for families who have children with emotional, behavioral or mental disorders.

Please describe how well you think you will be able to carry out important activities such as fund-raising, advocacy, public speaking, attending Board Meetings on a regular basis and participating in Federation work.

Please provide an assessment of your ability and experience in the following:

Ability to engage in fund-raising activities: — Yes No Unknown

Willingness to advocate in a variety of settings: — Yes No Unknown

Ability to deal effectively with organizational problem solving: — Yes No Unknown

Ability to develop and influence policy: — Yes No Unknown

Ability to engage in public speaking: — Yes No Unknown

Ability to provide leadership: — Yes No Unknown

Ability to serve as an ambassador for the IDFFCMH: — Yes No Unknown

Ability to be a spokesperson for the organization: — Yes No Unknown

Energy and enthusiasm for the Federation: — Yes No Unknown

Knowledgeable about the needs of children with mental, emotional and behavioral disorders and their families, or willing to learn: — Yes No Unknown

Cite specific examples of any or all of the above.

Please feel free to add any further comments that you believe would be helpful in our decision making process.