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Washington County Department of Human Services Advisory Board Member Application
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Name
*
Address
*
City
*
State
*
ZIP
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Phone
*
Email
Preferred method of contact
Phone
Email
Are you a Washington County resident?
Yes
No
Which stakeholder group do you represent?
*
Current/Former Recipient of Services
Aging Services
Drug & Alcohol Services
Veterans Affairs
Faith Based Community
Medical Provider
Community Leadership
Family/Community Member
Behavioral Health and Developmental Services
Housing and Homeless Services
Child Care
Food Bank/Local Pantry
School, University and/or College
Service Provider
Children and Youth Services
Victim Centered Organization
Employment and Training Specialist
Law Enforcement
Other Client Advocate
Please list community organizations, boards of committees of which you are an active or former member.
What is the reason you are interested in being on the Washington County Department of Human Services Advisory Board? Please attach additional pages if needed.
Additional pages
Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)
Please attach the results of your Act 33, Act 34, and FBI Clearances
Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)
Please specify timeframe during which you are most likely available for meetings
Monday: 8:30am-11:00am
Monday: 11:00am-1:00pm
Monday: 1:30pm -3:30pm
Monday: 5:30-7:30pm
Tuesday: 8:30am-11:30am
Tuesday: 11:00am-1:00pm
Tuesday: 1:30pm -3:30pm
Tuesday: 5:30-7:30pm
Wednesday: 8:30am-11:30am
Wednesday: 11:00am-1:00pm
Wednesday: 1:30pm -3:30pm
Wednesday: 5:30-7:30pm
Thursday: 8:30am-11:30am
Thursday: 11:00am-1:00pm
Thursday: 1:30pm -3:30pm
Thursday: 5:30-7:30pm
Friday: 8:30am-11:30am
Friday: 11:00am-1:00pm
Friday: 1:30pm -3:30pm
Friday: 5:30-7:30pm
We thank you for your interest. Press submit below and someone will review your application shortly.
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