Apply Online to Become a DRP Board Member

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MISSION STATEMENT: Disability Rights Pennsylvania protects and advocates for rights of people with disabilities so that they may live the lives they choose, free from abuse, neglect, discrimination, and segregation.

VISION STATEMENT: A Commonwealth where people of all abilities are equal and free.

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If you would prefer to fill out our physical application and return it, instructions can be found below. If you would like to continue to the online application, please click next.

DOWNLOAD APPLICATION TO BECOME A DRP BOARD MEMBER
Download Application in Word

Please return your completed application and any additional documents (e.g. your resume) to:

Samyra Bethune, Administrative Assistant
Disability Rights Pennsylvania
301 Chestnut Street, Suite 300
Harrisburg, PA 17101

You can also fax your application materials to Samyra at 717-236-0192 or email it to Samyra at: sbethune@disabilityrightspa.org.

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Which are you applying for? You may select one or both options.* This field is required.

Board of Directors

Mental Health Advisory Council (MHAC)

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Full Name* This field is required.

First Name

Middle Name

Last Name

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Street Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

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County of Residence* This field is required.

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Primary Phone* This field is required.

Please enter a valid phone number.

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Secondary Phone

Please enter a valid phone number.

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Work Phone

Please enter a valid phone number.

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Fax

Please enter a valid phone number.

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Email Address* This field is required.

example@example.com

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Social Media Usernames (Optional)

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Do you have a disability?* This field is required.

Yes

No

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What is your disability (Optional)

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Do you have a mental illness?* This field is required.

Yes

No

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Are you a family member of a person with a disabilty?* This field is required.

Yes

No

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What is your relationship to the person with a disability?* This field is required.

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OPTIONAL: Please list your child's age and disability

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Please select all that apply. I am...* This field is required.

A family member of a person with mental illness

A consumer or former consumer of mental health services and/or disability services

A primary caregiver for a minor receiving mental health services

An attorney with mental health experience and/or knowledge of mental health law

A mental health provider

A mental health professional

A public person knowledgeable about mental illness

Other

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Explain your interest and motivation in joining DRP’s Board and/or MHAC.* This field is required.

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List your relevant skills, training, and qualifications for joining DRP’s Board and/or MHAC.* This field is required.

If none, please write N/A

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List your Non-Profit Organization Experience. Please include your experience(s) with governance of non-profit organizations, including any leadership, committee, fundraising, or policy development experience.* This field is required.

If none, please write N/A

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List all boards, committees, and councils on which you currently serve.* This field is required.

If none, please write N/A

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List any disability-related advocacy groups on which you serve or have served.* This field is required.

If none, please write N/A

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List your affiliations with civic groups, corporations or foundations.* This field is required.

If none, please write N/A

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List what you believe to be the TOP THREE disability and/or MH issues in Pennsylvania. Describe your knowledge of issues affecting persons with disabilities and/or a mental health diagnosis.

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Special Interests/Additional Information. Please provide any additional information or special interests that you feel would be helpful to the Nominating Committee. For example, what do you believe you can contribute to the Board, the MHAC, and DRP? This information can include a resume, letter or additional information about your knowledge, background or involvement in mental health and/or disability issues.* This field is required.

If none, please write N/A

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Please list two references (name, position, relationship, phone):* This field is required.

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Please describe your connection to DRP and list acquaintances with any DRP staff, Board members or MHAC members.* This field is required.

If none, please write N/A

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Gender

Male

Female

Non-Binary

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DRP does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services. DRP is committed to providing an inclusive and welcoming environment for all members of its staff, volunteers, subcontractors, vendors, and clients.

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File Upload

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Max file size is 20 MB. Files must be PDF or Word Documents.

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This form is protected by reCAPTCHA. Please complete the CAPTCHA if prompted, then hit Review and Submit.* This field is required.