Citizen Review Panel 2021

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Application to volunteer for United Way's Citizen Review Panel

Email *

What is your full name?

What is your address?

What is your phone number?

In which community would you like to serve?

Clare

Gladwin

Both

Other:

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I want to serve on the Gladwin County Citizen Review Panel located at the Beaverton Activity Center (106 Tonkin St., Beaverton) : (You may serve on both days.)

Tuesday April 20, 12:30 pm- 4:00 pm

Wednesday April 21, 10:00 am -12:00pm

Wednesday April 21, 12:30-2:30 pm

I want to serve on the Clare County Citizen Review Panel located at the Clare United Way office (106 W. 7th St., Clare) : (You may serve on both days.)

Tuesday April 27 10:00 am- 12:00 pm

Tuesday April 27 12:30 pm-2:30 pm

Wednesday April 28 1:00 pm- 3:00 pm

Wednesday April 28 3:30-5:30 pm

Option 1

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Please inform us of any conflicts of interest you may have in performing duties as a member of the 2021 Citizen Review Panel. We would consider you to have a conflict of interest if you or a member of your household is employed by a partner agency, if you serve on the board of a partner agency, or if you receive services from a partner agency. If you believe you have a conflict of interest regarding any of the following partner agencies, please disclose such by checking the appropriate box(es). If you have no conflicts of interest, please leave blank.

2-1-1 of Northeast Michigan

The Arnold Center

Clare County Habitat for Humanity

Clare-Gladwin Great Start Collaborative

Gladwin County Council on Aging

Girl Scouts Heart of Michigan

Gladwin Child Abuse and Neglect Prevention Council

Gladwin YoungLife

Listening Ear Crisis Center

Mid Michigan Crossroads Council Boy Scouts

Mid Michigan Community Action Agency

MidMichigan Home Care

Mid Michigan Industries

Northern Michigan Alliance for Children

RISE Advocacy

Shelterhouse

Ten Sixteen Recovery Network

If you checked any of the boxes, please describe your relationship with the partner agency or agencies you selected. (Example: Employee or family member of employee, board member, etc.)

Any comments?

A copy of your responses will be emailed to the address you provided.

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