Community Advisory Committee

To be eligible you must be a resident of Arkansas and be at least 18 years of age. Please check the boxes below to confirm. *

I live in Arkansas

I am age 18 or older

First Name *

Last Name *

Email Address *

Phone

Phone Access

Voice Only

Voice and Text

Text Only

Address Line 1 *

Address Line 2

City *

State

Zip Code *

There are categories of membership on our Community Advisory Committee that are required by the Developmental Disabilities Act.

Individual with a Developmental Disability
Family member of an individual with a Developmental Disability
Representative of a state agency, local agency or nonprofit agency that serves individuals with Developmental Disabilities.

Developmental Disabilities is an umbrella term that includes disabilities that occur before the age of 22, impact an individual’s daily activities and are likely to be lifelong. The disability may be intellectual/cognitive, neurodevelopmental, physical or a combination.

I am a: *

Person with an Intellectual / Developmental Disability

Family member of an individual with an Intellectual / Developmental Disability

Representative of a state agency, local agency or nonprofit agency that serves individuals with Intellectual / Developmental Disabilities

Please list the type of disability/disabilities you or your family member have. (This helps us ensure broad representation.) *

Please list the name of the organization or agency you represent.

Please state your interest in serving on the Partners Community Advisory Committee: *

Please explain what you think “inclusion” means when discussing individuals with disabilities. What does this mean to you? *

Please share any other particular qualifications or experiences with disability that you feel would benefit the Partners Community Advisory Committee: *

Optional: We strive for diversity in representation. Responding to these questions on race/ethnicity may help us achieve that goal. You may check more than one box or choose not to respond. *

Asian / Pacific Islander

African American / Black

American Indian / Alaskan Native

Caucasian / White

Latino / Hispanic Ethnicity

Middle Eastern

Bi-racial or Multi-racial/ethnicity

Other

I prefer not to respond

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Community Advisory Committee

What is the Partners Community Advisory Committee?

What is the Committee’s Purpose?

What are the Responsibilities of a Committee Member?

What Do I Do if I’m Interested in Serving?

Know someone else who might like to join us?

Community Advisory Committee Consideration Form

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