MDHHS-5845, GUY THOMPSON PARENT ADVISORY COUNCIL (GTPAC) MEMBERSHIP APPLICATION

Michigan Department of Health and Human Services

(Revised 8-21)

eligibility

Parents who are actively participating in or previously serviced by a Michigan Department of Health and Human Services (MDHHS) family preservation program or the child welfare system, including Children’s Protective Services (CPS) or foster care.

participation

The Advisory Council assists the MDHHS and partner agencies by developing recommendations or suggestions for improving child welfare responses to families and providing input on policy development. Members participate in quarterly meetings and work to achieve objectives through additional activities such as: Developing and reviewing policies and procedures. Participating in engagement opportunities such as workgroups, advisory boards, or steering committees that inform programs and policies. Participating in legislative advocacy or testimony. Participating in forums and presentations involving child welfare stakeholders. Otherwise engaging in positive advocacy on behalf of children and families impacted by the child welfare system.

term of appointment

Term is a two-year appointment. Members must commit to participating in both council meetings and engagement opportunities.

REIMBURSEMENTS/INCENTIVES

Reimbursement for approved travel at state rate. Participation incentives will be provided as outlined in the GTPAC Operating Guidelines.

MEMBERSHIP APPLICATION INSTRUCTIONS

Send membership application along with two letters of support/recommendation via: Email: MDHHS-GTPAC@michigan.gov or Mail: Grand Tower Building OCWPP Attn: GTPAC 235 South Grand Avenue, 5th Floor Lansing, MI 48933 Questions: If you have questions or need assistance in completing this form, email MDHHS-GTPAC@michigan.gov

disclaimer

Application does not ensure membership appointment. The applicant-provided email address noted in this application will be used for primary communication unless otherwise noted in special accommodations. Having no access to transportation or phone does not prohibit appointment.

GUY THOMPSON PARENT ADVISORY COUNCIL (GTPAC)

MEMBERSHIP APPLICATION

Michigan Department of Health and Human Services

application information

Full Name (Last, First, Middle Initial)	Date

Street Address	Apartment/Unit Number

City	State	Zip Code

Phone Number	Email (Required – Primary form of communication)

Gender (optional)	Race (optional)

Please note: Race and gender questions are included to ensure diverse and representative participation in workgroups. If you do not feel comfortable answering those questions, you may enter N/A without any impact.

Do you have access to transportation? Yes No	Do you have access to a phone? Yes No

Have you ever worked for MDHHS or private agency? Yes No	If yes, where?

Are you able to attend required quarterly meetings? Yes No	If no, explain

Are you willing to carpool members to events? (not required) Yes No Possibly

Program involvement – Provide dates of applicable current or previous service involvement

Family Preservation Program Yes No	To	From

Children’s Protective Services Program Yes No	To	From

Foster Care Yes No	To	From

Other (explain)	To	From

May we call your caseworker (optional) Yes No

Name of Caseworker	Phone Number	County

experience – Include any MDHHS/Privacy Agency committee or project participation

Company	Job Title

Address

Supervisor Name and Contact Information

Company	Job Title

Address

Supervisor Name and Contact Information

other

Desired Program Areas of Interest (Identify any program interests, for example: policy review, presenting, specific maltreatment topics)

Do you require special accommodations (i.e. dietary, travel, phone accessibility, other)?

disclaimer and signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to appointment, I understand that false or misleading information in my application or interview may result in my release.

Signature	Date

Additional Include two letters of support and/or recommendation (required). You may also include any additional information, if desired, e.g. resume, cover letter (not required). Application can be sent either via email or mail. Email: MDHHS-GTPAC@michigan.gov Mail: Grand Tower Building OCWPP Attn: GTPAC 235 South Grand Avenue, 5th Floor Lansing, MI 48933

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.
AUTHORITY INFORMATION