Please provide the following contact information:

First Name
Last Name
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
County
Work Phone
Home Phone
FAX
E-mail

Please indicate which of the following group(s) best represents you (check all that apply):

Parent of a child with special needs   Health/Medical Representative          Educational Representative             Social Services Representative       
Head Start Representative   	           Child Care Representative                 Child's Age                            

I am interested in serving on the following committee: 

Public Awareness/Child Find   	Family Outreach & Quality Assurance         Functions of the LPCC                 
Provider Recruitment  	           	Transition               

The Central Indiana First Steps Cluster G Bylaws (Article 6, Section 11) state:

"Any council member whose organization(s) receives grants or other fund sources accessed through the Council shall avoid the possible perception of a conflict of interest by abstaining for the record from voting on measures which involve funding for that organization. No council member shall make demands or exert any pressure on any council employee to direct choice of provider or authorizations of service, to themselves or the agency they represent or any personal interest."

 My signature below indicates that I agree to be a Council Member and that my participation will comply with the conflict of interest statement.