Planning and Management Council Volunteer Application - Aging & Long Term Care of Eastern Washington

The purpose of this form is to provide the Agency with information about you that will assist our Nominating Committee in their selection process.

Home Phone(Required)

Cell Phone(Required)

Email(Required)

WA State Legislative District(Required)

Race/Ethnic Origin (optional)

What is your present/past work experience?(Required)

Why are you interested in becoming a member of the Planning and Management Council?(Required)

What would you say are the emerging issues facing seniors and other persons in need of Long Term Care?(Required)

What do you see as the role of the public and private sector in providing Long Term Care?(Required)

What role(s) would you like to perform on the Planning and Management Council - Other(Required)

How much of a time commitment are you willing to make weekly or monthly as a volunteer? (8 hours a month is the minimum requirement)(Required)

Reference 1 - Phone(Required)

Reference 2 - Phone(Required)

Reference 3 - Phone(Required)

Emergency Contact - Phone(Required)

Emergency Contact - Relationship(Required)