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FASD Task Force Interest Form

Thank you for your interest in participating in our Fetal Alcohol Spectrum Disorders (FASD) Task Force!

The FASD Task Force will be convened in January through the Summer of 2025 and we hope to meet up to once a month for no more than two hours. The objectives of this group will be to validate and interpret our project findings, develop recommendations, and identify appropriate channels and audiences to share them with. We also hope to ask Task Force members to reach out to their connections and professional networks where appropriate to help with the dissemination of information from this project. Task force members will be compensated for their time.

Please fill out this form to indicate your interest and share more about your background. In the upcoming weeks, we will reach out with further details regarding the next steps, including information about the committee's structure and meeting schedule.

First Name

* must provide value

Last Name

* must provide value

E-mail

* must provide value

Age (years)

Ethnicity

Hispanic or Latino NOT Hispanic or Latino Unknown

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Race

* must provide value

American Indian/Alaska Native (Please indicate tribal affiliation)

Asian

Native Hawaiian or Other Pacific Islander

Black or African American

White

Other

Prefer not to say

Gender

Female

Male

Nonbinary, Transgender, Gender-nonconforming

Prefer not to say

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If you interact with children and families affected by FASD in a professional role, what type of service or organization do you work in?

Education

Behavioral and mental health services

Child welfare services

Legal or advocacy services

Clinical services

Social services

Nonprofit/community-based

Other

What county or counties are you representing, either as a community member or through the services you provide?

* must provide value

How would you rate your ability to commit to regularly attend monthly meetings (lasting no more than two hours)?

* must provide value

Confident I can commit

Somewhat confident I can commit

Not sure

Not confident I can commit

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Please explain your role working with families impacted by FASDs, or how FASDs impact you/your family directly or indirectly.

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Why are you interested in joining this Task Force?

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What skills, interests, or connections do you bring to the table that would help advance the goals of the Task Force?

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Is there anything else you would like to add or anything else you would like us to know?

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