Application for
Policy Council for Children and Families Membership
If you wish to apply to be a member of the Policy Council for Children and Families, please fill out this application. The council works to improve the coordination, quality, efficiency and outcomes of services provided to children with disabilities and their families through the state's health, education and human services systems.
If a question does not apply to you, enter “N/A.”
You may also attach a resumé or certification.
HHSC will use the information you put on this application to decide if you are eligible to serve on this committee.
Important note: No compensation is provided to participants on this committee; however, members appointed as a family representative may be reimbursed for travel to and from meetings if funds are available.
HHSC won’t consider an application postmarked after Jan. 12, 2018.
SECTION 1 - Personal Information
5
Name:
Home Address:
City: State: TX ZIP: Phone:
Fax: Email:
Employment Information
Business/Organization:
Address:
City: State: TX ZIP: Phone:
Fax: Email:
Current Position Title:
Please check where you would like to receive further communications:
Work Email Home Email Work Address Home Address
Application
New/Initial Application Renewal Application
Gender
Male Female
Race/Ethnicity
American Indian/Alaskan Native Asian/Pacific Islander
Black Hispanic
White Other
5
SECTION 2 (Family/Individual Applicants Only)
The Policy Council for Children and Families will include members from families of children and young adults (under age 26 years) with disabilities. A family member or a person with a disability himself or herself may apply to be on the council. A "family member" may be the parent, spouse, guardian, grandparent or adult sibling of the person with a disability.
Please complete SECTION 2 only if you are a family member or a person with a disability.
Please tell us about your direct experience with and knowledge of Texas publicly funded programs serving children with disabilities and their families, including Medicaid, behavioral health, long term services and supports, 1915(c) home and community-based waivers, family and protective services and school and education based programs.
5
Please tell us why you want to serve on this council.
Please list any relevant personal and professional achievements and other knowledge, skills and abilities that address contributions you could make to the council.
5
SECTION 3
The member selected for the council must meet one of the following categories. Please check the category or categories that apply to you. (You may choose more than one category.)
5
A parent or family member from a family with a child under the age of 26 years with a disability.
An adolescent or young adult under the age of 26 years with a disability who receives services from a health and human services agency.
A parent or family member from a family with a child under the age of 26 years with mental health care needs.
5
Member Participation
Every member appointed to the Policy Council for Children and Families must attend regularly and must participate in subcommittee activities.
· Regular council meetings are held once every three months. The presiding officer also may call a special council meeting. Members must travel to Austin or another location for these meetings. Each meeting may last several hours.
· Subcommittee meetings may occur at other times. Members must travel to Austin or another location for these meetings or participate by phone. Each meeting may last several hours.
· Sometimes, members participate in other activities in their home communities. These activities might include town hall meetings or presentations.
Do you believe you will be able to regularly participate in committee activities, if you are appointed?
5
No Yes
If no, please explain:
5
Miscellaneous Information
Do you have a personal or private interest in a matter pending before a Health and Human Services system agency? ("Personal or private interest" means you have a direct monetary interest in the matter or owe your loyalty to an entity involved, but does not include the member's engagement in a profession, trade or occupation when the member's interest is the same as all others similarly engaged in the profession, trade or occupation.)
5
No Yes
Have you ever been convicted of a felony or misdemeanor (excluding traffic violations)?
No Yes
If yes, please explain:
5
References
Please provide the names and contact information for two people who can tell us more about your qualifications to serve on the council. References can include employers, clients, religious leaders, community leaders, advocates, friends or others who know about your interest in and/or involvement with improving services for children with a disability and their families.
5
Reference #1
Name:
Address:
City: State: ZIP:
Daytime Phone:
Email:
Relationship (how this person knows you):
Reference #2
Name:
Address:
City: State: ZIP:
Daytime Phone:
Email:
Relationship (how this person knows you):
5
All the information contained in this application is true and correct. I understand that the council will meet in Austin or another location at least four times per year. If selected, I will make every effort to attend all council meetings.
5
Signature (typed name is acceptable) Date
5
Please return this form and any supporting documentation to:
Email:
Attn: Jimmy M. Blanton
Mail: Texas Health and Human Services Commission
6330 East Highway 290, Suite 100
Austin, Texas 78723
Attn: Jimmy M. Blanton
Fax: 512-380-4380
Attn: Jimmy M. Blanton
If you have any questions about the application or the Policy Council for Children and Families, please contact Jimmy M. Blanton at 512-380-4372 or by email at .
5