New Model for Supporting Disabled People

National Reference Group

Nomination Form

Name / Phones
Address / email
Please submit this form to Inclusion Aotearoa.
Contact details are at end of this form.
Closing date: Friday 26 October 2012 / Support Needs:
If you will need support in this work, you can include details below or do so later.
Support needs will not be part of the criteria for selection of members. They will be discussed following the selection process.
Please note the areas of expertise sought are:
·  knowledge and understanding of NASC processes
·  knowledge and experience of Deaf culture
·  experience of moving from a residential service to a community setting.
Please continue on another sheet if you need more space.
Personal and/or work experience of disability/impairment
Ethnicity
Iwi affiliation
The reason you would like to be on this reference group
Specify the relevant
1.  values
2.  skills
3.  knowledge
you would bring to the working group / …………………………………………………………………………..
……………………………………………………………………………
………………………………………………………………………......
Current & former roles in the disability sector, including leadership
Other relevant experience –e.g. cultural knowledge, previous roles or qualifications
Describe your commitment to the philosophy, intent and implementation of the New Model
Note those aspects of the New Model you think are significantly different from current disability supports
List any particular areas of interest or expertise in relation to specific parts of the New Model
Networks you can commit to report to
Referees or endorsements from disability organisations or people in the disability sector / Please note contact details for at least two referees the selection panel can contact..
If you have any conflicts of interest please note them
Tick box: / I am available for meetings in Auckland:
·  Wed 28 November (induction for new members only)
·  Thursday 29 November (9- 3.30)
Signature
Email or post completed forms to / Ruth Gerzon
email
P O Box 3017, Ohope, Whakatane 3161
Note: This form must reach Inclusion Aotearoa by 5 pm on Friday 26 October 2012

National Reference Group Nomination Form October 2012 1