2023 PARENT ADVISORY COUNCIL APPLICATION

This is an application for individuals interested in becoming a volunteer for SBA's Parent Advisory Council. The Council is a champion of the SBA and all families within the Spina Bifida community. Members contribute to SBA's mission by sharing their expertise; understanding of diverse perspectives; their connections to local, national or international colleagues or peers; their philanthropic support; or other forms of needed assistance.

Please learn more about the Council by completing this application after reading the Parent Advisory Council Charge. You may submit an application at any time.

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* 1. Name:

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* 2. Contact Information

State:

Phone:

Email:

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* 3. Have you read and familiarized yourself with the Parent Advisory Council Charge found on SBA's website before submitting this application?

Yes

Your answers to the following questions will guide SBA's efforts to include a diverse group of applicants.

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* 4. What is your relationship to Spina Bifida? Check all that apply.

I am an adult with Spina Bifida

I am or was a parent or caregiver of a child or adult with Spina Bifida

I have or had a family member with Spina Bifida

I am a medical professional who works with the Spina Bifida community

Other (please specify)

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* 5. What is your ethnicity?

White

Hispanic / Latino

Black / African American

Native American

Asian/ Pacific Islander

I prefer not to answer this

Other (please specify)

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* 6. What is your gender?

Female

Male

Non-binary

Something else

I'd prefer not to answer

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* 7. Please share your preferred pronouns.

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* 8. What is your age?

25-34

35-44

45-54

55-64

65+

Other (please specify)

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* 9. How old is your child or the child you are a caregiver for?

My child is

The child or adult I am a caregiver for is

Not applicable

Please tell us about your experiences and interests.

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* 10. Have you ever served as a member of an advisory board, committee, or board of directors for a non-profit before?

Yes. Please indicate the organization(s).

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* 11. Why do you want to join SBA's Parent Advisory Council?

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* 12. What qualities or experience are you excited about bringing to this committee?

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* 13. What's one thing you'd love to accomplish as a member of this committee?

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* 14. What's one thing you'd love for us to know about you and one thing that you'd love for us to know about your child with Spina Bifida?

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* 15. What's been one of the most valuable things you've learned about being a parent/caring for someone living with Spina Bifida?

Lastly,

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* 16. Do you have any conflicts of interest to disclose? This could include private or personal interests, or work (whether paid or volunteer) for another organization or company with which SBA has a relationship with.

Not sure

Yes (please explain)

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* 17. Electronic Signature (print name)

Thank you for completing this form. We will review all applications in January 2023 and will be in touch with you soon after that.