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
Gender Identity
Ethnicity
(example: White/Caucasian)
SILC Representation
Please check all the areas that apply to you:
Accommodation Requests

Please check the appropriate box or provide a written description of your need:
Options:

Other
Business/Work Information - (Optional)
Are you employed by a State Agency?
Are you an employee, board member or volunteer of a Center for Independent Living?
What is your employer's name or N/A
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?
The NC SILC has 3 standing committees. Please check all that you would be interested in joining.
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
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NC Statewide Independent Living Council Membership Interest Form

Personal Information

Demographic Information

SILC Representation

Accommodation Requests

Business/Work Information - (Optional)