Lansdowne Family Advisory Council (FAC) Application Form

Application Form

Family Advisory Council (FAC)
By submitting this application, I am expressing my interest in participating in the Family Advisory Council (FAC).

I recognize and confirm that I will be available to attend meetings/events through the calendar year and that my active participation is vital to the successful operation of the Family Advisory Council (FAC).
Applicant Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
I prefer to be contacted...*
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
My relationship to the child is a...*
My child is currently...*
Which Lansdowne service(s) has your family accessed (please check all that apply)

Autism ServicesPhysiotherapy (PT)Occupational Therapy (OT)Speech & Language Therapy (SLT)Infant and Child Development (ICDP)Early Integration Program (EIP)Recreation ServicesRespite ServicesDevelopmental PaediatricianSocial WorkService NavigationOther
I understand that Lansdowne requires that I submit the results of a criminal reference and vulnerable sector check.*

I agree to these termsOther
I understand that in order to encourage participation of family members across our catchment region of Grand Erie (including Brantford, Counties of Brant, Haldimand and Norfolk, Six Nations of the Grand River, and Mississaugas of the Credit First Nations) the Family Advisory Council (FAC) will meet using a hybrid (in-person & virtual) model. Participants attending in-person must provide record of receiving at least two COVID-19 vaccines.*

I agree to these termsOther
Please share what skills you will add, and what motivates you to participate
What barriers to volunteering do you anticipate? How can we help?
I prefer to meet... (please check all that apply)

During the day, Monday to FridayDuring the evening, Monday to FridayIn person at Lansdowne BrantfordVirtually using a streaming video service such as Zoom, MS Teams
Should be Empty: