Engaging Families and Young Adults Program
Placement Agency Interest Form
Placement Agency Interest Form
Please provide your agency and contact information. Share ways in which you envision your agency engaging a Young Adult and/or Family Advisor. A representative from Diverse Ability Incorporated or Raising Special Kids will contact you on behalf of the Engaging Families and Young Adults Program (EFYAP). Please note that Placement Agencies compensate Advisors for their time.
Name
*
First Name
Last Name
Title or Role
Organization/Agency Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
County
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Areas of Interest:
*
Hosting a Family Advisor
Hosting a Young Adult Advisor (age 18-26)
Hosting Both
Undecided
How did you hear about the Engaging Families and Young Adults Program?
*
Ways that your agency might engage a Young Adult or Family Advisor:
*
A brief description of how you might engage an Advisor(s) in your agency. What would their role(s) be? How often would they engage with your organization? Are you looking for board, committee, or task force members? Focus group participants?
When your agency would like to engage an Advisor in your work:
*
Target date for getting an Advisor placed within your agency, whether it be to serve on a committee, board, task force, etc.
Submit
Should be Empty: