Westside Regional Center Board of Directors Application Form

BOARD OF DIRECTORS APPLICATION
The Westside Regional Center Board (WRC) of Directors consists of volunteers from the catchment area served by WRC. Board members play an important role in providing oversight for WRC. One purpose of our Board is to keep WRC connected to community members and receptive to their needs.
Name*

First NameLast Name
Do you work and/or live within the WRC Catchment Area?*

YesNo
If Yes, what city?*

Bel AirBeverly HillsBeverlywoodCentury CityCulver CityEl SegundoGardenaHawthorneInglewoodLawndaleLos AngelesMalibuMar VistaMarina del ReyPacific PalisadesPlaya del ReySanta MonicaVeniceWestwood
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from home address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Phone Number*
Please enter a valid phone number.
Evening Phone Number*
Please enter a valid phone number.
Mobile Phone Number*
Please enter a valid phone number.
What is the best phone number to reach you?*

Daytime Phone NumberEvening Phone NumberMobile Phone Number
Employment/Occupational Status*

Full-Time/Part-TimeRetiredDay ProgramNot Currently WorkingOther
If you selected "Other" please explain
Employer
Position
Educational Background
Professional or Occupational Background
Section 2
How did you develop an interest in or knowledge of developmental disabilities?*
Describe your employment, education, personal circumstances, or other activities which demonstrate your interest or knowledge).
Areas of expertise you would bring to the WRC Board (check all that apply):*

Accounting/FinancialAdministration/ManagementPerson Served by WRCAdvocacyDevelopmental Disability Program SkillsEducationLawPublic RelationsSelf-Advocacy
How might your background and experiences help the WRC Board?
Please list all current and recent (last 5 years) memberships in associations, service clubs, social clubs, occupational groups, professional organizations, and developmental disability affiliations.
Please list all offices and other positions of responsibility you have held in the groups or organizations listed above.
Section 3
Gender Identity

MaleFemaleNon-Binary
Ethnicity/Race (Check One)

AsianAmerican Indian or Alaska NativeBlack or African AmericanCaucasianHispanic or LatinoMultiracialNative Hawaiian or Other Pacific Islander
Are you a person served by WRC?*

YesNo
If the answer is yes:
If you become a WRC Board Member, will you require transportation?*

YesNo
Will you require facilitation (assistance) in preparing for and participating in meetings?*

YesNo
Are you a relative, conservator or guardian of a person served by WRC?*

YesNo
If the answer is yes:
What is the relationship? (Please describe)
What is the age range of the person served by WRC with whom you have the relationship?

0-3 years4-18 years19-22 years23-39 years40+ years
If you are a person served by WRC or have a relationship to a person served as described above, please check all that apply to the person served by WRC

AutismCerebral PalsyEpilepsyIntellectual DisabilityOther
If you selected Other, please specify:
Do you have prior membership on a regional center Board?*
If the answer is Yes:
Please provide the name of the Regional Center*
Please provide your years of service and offices held:
Are you or is any member of your family an employee or Board member of any business entity that provides services to persons served by any regional center?*

YesNo
If the answer is Yes, please explain
Are you or is any member of your family an employee or a member of the State Council on Developmental Disabilities?*

YesNo
If the answer is Yes, please explain
Are you or any member of your family employed by the State Department of Developmental Services (DDS) or any state or local agency that provides services to persons served by regional centers?*

YesNo
If the answer is Yes, please explain
Section 4
How did you hear about the Board of Directors?*
Please describe why you would like to serve on the WRC Board*
Have you had personal experiences with members of the WRC Board or WRC employees?*
Is there anything you have seen or experienced that, in your opinion, should be improved or changed at WRC?
Is there anything you would like to favorably comment on regarding WRC?
The work of the Board of Directors requires consistent attendance at monthly meetings of the Board of Directors and Board committees. These meetings may be more than two hours.
Are you available for Committee Meetings?*

YesNo
Which Committees would you be interested in attending? (Check all that apply)*
Section 5
Please provide the name, address, and phone number of one reference (personal or professional)
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Please completely answer all of the above questions. You are welcome to submit a resume or additional statement of interest in participating in the WRC Board of Directors.

Welfare and Institutions Code, Section 4626. (a) In order to prevent potential conflicts of interest, no member of the governing board or member of the program policy committee of a regional center shall be any of the following:
1. An employee of the State Department of Developmental Services or any state or local agency which provides services to a regional center client, if employed in a capacity which includes administrative or policy making responsibility, or responsibility for the regulation of the regional center.
2. An employee or a member of the State Council.
3. Except as otherwise provided in subdivision (h) of Section 4622, an employee or member of the governing board of any entity from which the regional center purchases client services.
4. Any person who has a financial interest, as defined in Section 87103 of the Government Code, in regional center operations, except as a consumer of regional center services.
Title 17 Section 54520. Conflict of Interest Standards for Regional Center Governing Board Members.

a. The following constitute conflicts of interest for regional center governing board members:
1. A conflict of interest exists when a member of the governing board or a family member of such person is a director, officer, owner, partner, shareholder, trustee or employee of any business entity or provider, holds any position of management in any business entity or provider, or has policy- making authority in such an entity or provider, except to the extent permitted by Welfare and Institutions Code, Section 4626(a)(3) and (b). These conflict-of-interest provisions are in addition to those stated in Welfare and Institutions Code, Sections 4622(a)(9) and 4626.
I do not have any ofthe Conflicts of Interest as stated above*

I do not have any ofthe Conflicts of Interest as stated above
Signature*

Powered by Jotform Sign Clear
Print Name
Date

MonthDayYear
Date
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform

BOARD OF DIRECTORS APPLICATION

Section 2

Section 3

If the answer is yes:

If the answer is yes:

If the answer is Yes:

Section 4

Section 5