LGBTQ+ Advisory Panel - Member Application LGBTQ+ Advisory Panel - Member Application LGBTQ+ Advisory Panel - Member Application Name * First Name Last Name Chosen or Preferred Name (If Applicable) Organization, Company or Affiliation (current or most relevant in recent past) Email * Phone (###) ### #### Pronouns She/Her He/Him They/Them Ze/Zir Self-Identify Other Gender Identity Cis Female Cis Male Trans Female Trans Male Two-Spirit Non-Binary, Gender Non-Conforming, or Gender Fluid Decline to Answer Other Sexual Orientation Lesbian Gay Bisexual Pansexual Queer Straight Questioning/Unsure Decline to Answer Other Racial Identity African American or Black Asian or Pacific Islander Latino/a Native American or Indigenous White/Causcasian Multi-Racial Decline to Answer Other If you answered "Other" to any question above, please specify. Professional Fields of Experience or Types of Organizations/Institutions You’ve Served: Government Agency (Public Health, Mental Health, or other) Social Services Academia or Educational Institution Media (Journalism, Advertising, Marketing, Influencer) Community-Based Organization or Non-Profit LGBTQ+ Advocacy Organization Other Professional Areas of Expertise and Relevant Experience : Research and Evaluation Media Campaigns or Public Education Initiatives Youth Services Training or Technical Assistance Social Justice Advocacy Mental Health Programming Other Text How did you hear about this opportunity to serve on the LGBTQ+ Advisory Panel? What is your experience relevant for an LGBTQ+ initiative? Professional experience working with or in LGBTQ+ communities Professional experience developing content or programs tailored for LGBTQ+ audiences Lived experience as a member of the LGBTQ+ community Other Please describe any professional, personal, or lived experience related to mental, emotional, and behavioral health (if relevant). Please select your preferred types of engagement as a potential member of the panel (noting only the first item is required for participation on panel, the others are optional) *Virtual Attendance at Quarterly Meetings (minimum level) Virtual Attendance at Monthly Meetings Ad Hoc Calls as Needed to Consult on Specific Questions or Review Documents Email Responses as Needed to Consult on Specific Questions or Review Documents Responding to Surveys or Polls In-person Attendance at Meetings in Sacramento, California Other Please tell us your eligibility and preference for participation incentives or compensation? I am an employee of the State of California, the United States Federal Government, or are otherwise ineligible for incentives for my participation. I am eligible for incentive and would prefer to be compensated for my time and participation. I am eligible for incentive, but would prefer to donate my time. Anything else you'd like to share about yourself or your experience to help us determine the best fit for the panel? Thank you!
