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AWA Board of Director Application
Please provide answers to the following questions to be considered for the Arkansas Waiver Association Board of Directors.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Address
*
Your answer
City, State, Zip
*
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Occupation
Your answer
Agency or Company (if applicable)
Your answer
Date of Birth
MM
/
DD
/
YYYY
Which category best describes you? (check all that apply)
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latinx or Spanish Origin
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
I prefer not to respond
Other:
How do you currently describe your gender identity?
Your answer
Do you have a disability?
Yes
No
Clear selection
If yes, please specify disability:
Your answer
Are you a parent or guardian of an individual with a disability?
Yes
No
Clear selection
If yes, please specify disability and age of the person with a disability:
Your answer
What experience have you had with community-based support services for individuals with disabilities?
Your answer
What experience have you had serving on boards or committees?
Your answer
Would you commit to attend quarterly board meetings of approximately three hours and provide additional support to committees and projects as needed?
Yes
No
Clear selection
What is your major interest in serving as an Arkansas Waiver Association board member?
Your answer
Why do you think you are a good candidate for this board?
Your answer
A copy of your responses will be emailed to the address you provided.
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