KPFC Board Member Application for Parents/Primary Caregiver & Agency Representative

A Parent/Primary Caregiver Representative is a person who is raising a child that has a behavioral health challenge: ADHD, anxiety, bipolar disorder, depression, post-traumatic stress disorder, substance use disability, and so many more. The Parent/Primary Caregiver Representative will share the perspective and voice for themselves and for other parents in their region of Kentucky. An Agency Representative is an employee of a state or private agency that provides services to families and children and has knowledge around behavioral health challenges. The Agency Representative will share resources, strategies, partnership opportunities, etc. with KPFC board members, staff, and customers.

Name

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Date

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer

Occupation

Please list your experience working on any board of directors of non-profit agencies, volunteer organizations or support groups.

If you are a caregiver/paretn, please give a brief description of the children under your care (age, gender, and disability) and the experiences you have had in caring and advocating for your children.

If you have been appointed to represent your agency on KPFC's board, please give a brief description of your job responsibilities and how they relate to KPFC. Also include hor your agency works with children and families.

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KPFC

KPFC Board Member Application for Parents/Primary Caregiver & Agency Representative

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