AdvisoryCommitteeApplication - Texas Department of State ...



Texas School Health Advisory Committee

Parent Member Application

If you wish to apply to be a member of the Texas School Health Advisory Committee (TSHAC), please fill out this application. The TSHACs role is to advise the Department of State Health Services (DSHS) on the support for and delivery of coordinated school health programs and school health services. If a question does not apply to you, enter “N/A.” The information you provide on this application will help DSHS in determining the most qualified applicant. Important note: Only TSHAC members in the Parent category will be reimbursed for travel expenses and must make their own travel arrangements. All other members will be responsible for their own travel expenses.

DSHS will not consider an application received or postmarked after July 31, 2017.

SECTION 1 - Personal Information

Name:

Home Address:

City: State: TX Zip: Phone:

Fax: Email:

Employment Information

Business/Organization:

Address:

City: State: TX Zip: Phone:

Fax: Email:

Current Position Title:

Please indicate where you would like to receive further communications:

Work Email Home Email Work Address Home Address

Application

New/Initial Application Renewal Application

Gender

Male Female

Race/Ethnicity

American Indian/Alaskan Native Asian/Pacific Islander

Black Hispanic

White Other

SECTION 2 (Parent Member Application - Parent of a school-age child)

A parent of a school-age child may apply to be on this committee. (A school-age child is one enrolled in a kindergarten through high school grade 12; and, that enrollment is current as of the deadline for submitting applications for membership in the TSHAC).

Please tell us about your direct experience with school health programs and school health services. Examples include: actively participating in your local school health advisory council, Parent Teacher Association, or campus improvement teams.

Please tell us why you want to serve on this committee.

List your relevant personal and professional achievements, including current licensures and activities that address contributions you could make to the committee:

Have you ever been disciplined by any licensing board/professional or civic organization, including the HHSC Inspector General?

No Yes

If yes, please explain:

Member Participation

Every member appointed to the TSHAC must attend regularly and must participate in subcommittee/workgroup activities.

• Regular committee meetings are held about once every two months, five times a year. The presiding officer also may call a special committee meeting. Members must travel to Austin for these meetings. Each meeting may last several hours.

• Subcommittee/workgroup meetings may meet at other times. Members must travel to Austin for these meetings. Each meeting may last several hours.

• Please note: travel expenses (mileage and/or airfare) to advisory committee meetings, subcommittee meetings, workgroup meetings, or any other activities are only reimbursable for Parent members. All other members are responsible for their own expenses.

Do you believe you will be able to regularly participate in TSHAC activities, if you are appointed? Yes No

If no, please explain:

Miscellaneous Information

Do you have a personal or private interest in a matter pending before the Texas Department of State Health Services? ("Personal or private interest" means you have a direct monetary interest in the matter or owe your loyalty to an entity involved, but does not include the member's engagement in a profession, trade, or occupation when the member's interest is the same as all others similarly engaged in the profession, trade, or occupation.)

Yes No

References

Please provide the names and contact information for two people who can tell us more about your qualifications to serve on the advisory committee. References can include employers, clients, religious leaders, community leaders, advocates, friends, or others who know about your interest in and/or involvement with service delivery.

|Reference #1 |Reference #2 |

|Name: |Name: |

|Address: |Address: |

| | |

| | |

|City/State/Zip: |City/State/Zip: |

| | |

|Daytime phone: |Daytime phone: |

| | |

|E-mail: |E-mail: |

| | |

|Relationship (how this person knows you): |Relationship (how this person knows you): |

|_____________________________________________________________________|_____________________________________________________________________|

|________________________ |________________________ |

Have you ever been convicted of a felony or misdemeanor (excluding traffic violations)?

No Yes

If yes, please explain:

All the information contained in this application is true and correct. I understand that the TSHAC will meet in Austin five times per year. If selected, I will make every effort to attend all advisory committee meetings.

__ Signature (typed name is acceptable) Date

Please return this form and any supporting documentation to:

Email: SchoolHealth@dshs.

Subject: TSHAC Member Application

Mail: Texas School Health Program

Texas Department of State Health Services

P.O. Box 149347, Mail Code 1925

Austin, Texas 78714-9347

Fax: 512-776-7555

Attn: School Health Program – Anita Wheeler

Subject: TSHAC Member Application

If you have any questions about the application or the Texas School Health Advisory Committee, please contact Anita Wheeler at (512) 776-2909 or by email at Anita.Wheeler@dshs..

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