Board and Mental Health Advisory Council Member Application

Thank you for your interest in DRP and the Mental Health Advisory Council (MHAC), and for taking the time to submit an application for membership.

All applications are reviewed by the joint DRP Board/MHAC Nominating Committee for membership eligibility. The Nominating Committee takes into account the current composition of the DRP Board and the MHAC, along with anticipated needs for new members. If the Nominating Committee determines that you are a good fit for the Board or MHAC, you will be contacted for an interview. Please note that not all persons who submit an application for membership are interviewed but you will be contacted either way.

MISSION STATEMENT: Disability Rights Pennsylvania protects and advocates for rights of people with disabilities so that they may live the lives they choose, free from abuse, neglect, discrimination, and segregation.

VISION STATEMENT: A Commonwealth where people of all abilities are equal and free.

Download Application to become a DRP Board Member

Download Application in Word

Please return your completed application and any additional documents (e.g. your resume) to:

Samyra Bethune, Administrative Assistant
Disability Rights Pennsylvania
301 Chestnut Street, Suite 300
Harrisburg, PA 17101

You can also fax your application materials to Samyra at 717-236-0192 or email it to Samyra at: sbethune@disabilityrightspa.org.

Apply Online to become a DRP Board Member

Which are you applying for?*
- Application for Board of Directors
- Application for Mental Health Advisory Council (MHAC)
- Application for both Board of Directors and MHAC
This application can be used to apply for the DRP Board of Directors, the Mental Health Advisory Council or both. Please indicate which membership you are applying for by checking one of the boxes above.
Personal Information
Full Name*
Street Address*
City
County*
Zip Code*
Home Phone*
Work Phone*
Cell Phone*
Fax
Email*
Social Media Usernames (Optional)
Do you currently have a disability?*
- Yes
- No
OPTIONAL: If you answered Yes, what is your disability?
Do you have a mental illness?*
- Yes
- No
Are you a family member of a person with a disability? If yes, please select the relationship(s) that apply:*
- Parent
- Partner/Spouse
- Child
- Sibling
OPTIONAL: If you are a parent of a child with a disability, please list your child’s age and disability:
Check all that apply:
- Family Member of a person with mental illness
- Consumer or former consumer of mental health services and/or disability services
- Primary Caregiver for minor receiving mental health services
- Attorney with mental health experience and/or knowledge of mental health law
- Mental health provider
- Mental health professional
- Public Person knowledgeable about mental illness
Information to Help us Know You
You can attach additional pages when completing this section. If you have a resume, please provide it when you submit your application.
Explain your interest and motivation in joining DRP’s Board and/or MHAC.*
List your relevant skills, training, and qualifications for joining DRP’s Board and/or MHAC.*
List your Non-Profit Organization Experience. Please include your experience(s) with governance of non-profit organizations, including any leadership, committee, fundraising, or policy development experience.*
List all boards, committees, and councils on which you currently serve.
List any disability-related advocacy groups on which you serve or have served.
List your affiliations with civic groups, corporations or foundations.
List what you believe to be the TOP THREE disability and/or MH issues in Pennsylvania. Describe your knowledge of issues affecting persons with disabilities and/or a mental health diagnosis.
Special Interests/Additional Information. Please provide any additional information or special interests that you feel would be helpful to the Nominating Committee. For example, what do you believe you can contribute to the Board, the MHAC, and DRP? This information can include a resume, letter or additional information about your knowledge, background or involvement in mental health and/or disability issues.
Please list two references (name, position, relationship, phone):
Please describe your connection to DRP and list acquaintances with any DRP staff, Board members or MHAC members.
Additional Personal Information
The information below is collected for federal reporting purposes. We also request this information, along with the demographic information in Section I., to assure a diverse and effective board and MHAC membership, and because Federal law (P.L. 99-319) requires the MHAC to include the following representation. Please check all that apply. Your assistance in providing the information is voluntary.
Race/Ethnicity (choose one):
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- White
- Hispanic or Latino
- Two or more races
- Other
- Decline to Answer
Gender
- Male
- Female
- Non-binary
Your Age Group
- 18 & under
- 19-35
- 36-59
- 60 & over
- Decline to Answer
DRP does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services. DRP is committed to providing an inclusive and welcoming environment for all members of its staff, volunteers, subcontractors, vendors, and clients.
Resume
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Board Member Application

Thank you for your interest in DRP and the Mental Health Advisory Council (MHAC), and for taking the time to submit an application for membership.

Download Application to become a DRP Board Member

Apply Online to become a DRP Board Member

Personal Information

Information to Help us Know You

You can attach additional pages when completing this section. If you have a resume, please provide it when you submit your application.

Additional Personal Information