HomeMy WebLinkAboutHSBG Committee Member Interest Form - Final Version - July 2018
COMMISSIONERS
Human Services Administrator’s Office David S. Keller, Chairman
Human Services Building Robert L. Thomas
425 Franklin Farm Lane Robert G. Ziobrowski
Chambersburg, PA 17202
www.franklincountypa.gov
Hearing Impaired Number: (717) 264-8474
Human Service Administrator
Telephone: (717) 261-3893 Stacie M. Horvath
Fax: (717) 261-0999 smhorvath@franklincountypa.gov
HUMAN SERVICES BLOCK GRANT
COMMITTEE MEMBER
INTEREST FORM
MISSION: Our mission is to assist in identifying needs-based program priorities for promoting the
health, well-being, and self-sufficiency for all people in Franklin County by and through the maximization
of HSBG resources.
DATE SUBMITTED:DATE RECEIVED:
NAME:
ADDRESS:
BEST CONTACT PHONE NUMBER: CELL: ______________(or)LANDLINE: ________________
EMAIL ADDRESS:
DO YOU CURRENTLY WORK and/or VOLUNTEER?_____ Yes (or)_____ No
IF YES, PLEASE LIST:
ORGANIZATION:
WORK ADDRESS:
TITLE orROLE:
DO YOU CURRENTLY or HAVE YOU EVER SERVED onANY ADVISORY BOARDSor COMMITTEES?
________Yes (or)________No
IF YES, PLEASE LIST:
PLEASE EXPLAIN WHY YOU ARE INTERESTED in BECOMING aMEMBER of theFRANKLIN COUNTY
HUMAN SERVICES BLOCK GRANT COMMITTEE? _____________________________________________________
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DO YOU HAVE ANY SPECIAL AREAS OF INTEREST/EXPERIENCE?
HOMELESS ASSISTANCE
MENTAL HEALTH
INTELLECTUAL DEVELOPMENTAL DISABILITIES CULTURAL DIVERSITY
DRUG andALCOHOLCRIMINAL JUSTICE
AGING SERVICESEARLY INTERVENTION/EDUCATION
CHILDREN andYOUTHHEALTH
VETERANSAFFAIRSEMPLOYMENT andTRAINING
F
OTHER(please list): ________________________
PLEASE PROVIDE ONE (1) REFERENCE of SOMEONE WHO has KNOWN YOU, EITHER PERSONALLY or
PROFESSIONALLY, for atLEAST ONE (1) YEAR.
Please Note that this Person will be contacted for a brief interviewby the Human Services Administrator
NAME:
TITLE orOCCUPATION:
EMAIL ADDRESS:
BEST CONTACTPHONE NUMBER:
BEST TIME of DAY to CONTACT: