PAIMI Advisory Council – Online Application

Full Name*

Phone Number*

Address*

Email*

Please tell us a bit about yourself:

Why are you interested in serving on the DRVT PAIMI Advisory Council?

What experience or skills do you have that would be valuable to DRVT regarding serving individuals with mental health conditions?

How did you learn about DRVT’s PAIMI Advisory Council recruitment?

Federal grants require that we have certain individuals represented on the PAC and they encourage diversity. Please complete any of the options below that apply to you and that you are comfortable sharing:<br>How do you identify yourself?

Race:

Gender Identity:

Sexual Orientation:

Other Important Identity:

We thank you on behalf of Disability Rights Vermont and the people we serve!

PAIMI Advisory Council – Online Application

Reach out to us for
assistance.

Reach out to us for
assistance.

PAIMI Advisory Council – Online Application

Reach out to us forassistance.

Reach out to us forassistance.

Reach out to us for
assistance.

Reach out to us for
assistance.