NC SILC Member Profile

NC Statewide Independent Living Council Membership Interest Form
Personal Information
Name*

First NameLast Name
Email address you would like to be contacted at*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County of residence:
Phone number*

Area CodePhone
Birth Date*

MonthDayYear
Demographic Information
MaleFemaleprefer not to answer
Ethnicity
(example: White/Caucasian)
SILC Representation
VisionHearing Loss or DeafCognitiveEmotional or Mental HealthParent of a school age child with a disabilityPhysical Disability
Accommodation Requests

Please check the appropriate box or provide a written description of your need:
ASLCARTLarge PrintNone are requestedOther
Business/Work Information - (Optional)
YesNo
YesNo
If you are employed, please list the name of your employer. If not employed, list n/a*
(example, Amazon)
Please tell us why you would like to be a NC Statewide Independent Living Council Member.*
Please list your current and past experiences serving on a nonprofit Board of Directors, advisory council, or state board or commission.*
What are your current associations and/or club affiliations (include titles if possible)*
What experiences, expertise, connections, or resources do you bring to NC SILC? *
Board Recruitment & GovernanceFinance & Human ResourcesResource Development & Program Committee
The success of the NC SILC requires everyone's participation. Board members are required to participate in a minimum of 4 quarterly meetings (typically are virtual) and participation in 1 monthly committee meeting, which occurs outside of regular board meetings (this can happen by phone or internet). Council members are expected to be timely and present at every meeting with no more than two absences from the quarterly board meetings per year. If you are appointed by the Governor, you will be required to complete additional paperwork and an online State Ethics training.

PLEASE ADD ANY ADDITIONAL INFORMATION YOU WOULD LIKE US TO CONSIDER
Should be Empty:

NC Statewide Independent Living Council Membership Interest Form

Personal Information

Demographic Information

SILC Representation

Accommodation Requests

Business/Work Information - (Optional)