Nomination Form â Local Working Group - Spectrum Care
Nomination Form â Local Working Group - Spectrum Care
Nomination Form â Local Working Group - Spectrum Care
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New Model for Supporting Disabled People<br />
National Reference <strong>Group</strong><br />
<strong>Nomination</strong> <strong>Form</strong><br />
Name<br />
Phones<br />
Address<br />
email<br />
Please submit this form to Inclusion<br />
Aotearoa.<br />
Contact details are at end of this form.<br />
Support Needs:<br />
If you will need support in this work, you can<br />
include details below or do so later.<br />
Closing date: Tues 29 March 2011<br />
Support needs will not be part of the criteria for<br />
selection of members. They will be discussed<br />
following the selection process.<br />
Filling in this form: Please continue on another sheet if you need more space.<br />
Personal and/or work<br />
experience of<br />
disability/impairment<br />
Ethnicity<br />
Iwi affiliation<br />
The reason you<br />
would like to be on<br />
this reference group<br />
Specify the relevant<br />
1. values<br />
2. skills<br />
3. knowledge<br />
…………………………………………………………………………..<br />
……………………………………………………………………………<br />
you would bring to<br />
the working group<br />
………………………………………………………………………......<br />
National Reference <strong>Group</strong> <strong>Nomination</strong> <strong>Form</strong> 1
New Model for Supporting Disabled People<br />
National Reference <strong>Group</strong><br />
Current & former<br />
roles in the disability<br />
sector, including<br />
leadership<br />
Other relevant<br />
experience –e.g.<br />
cultural knowledge,<br />
previous roles or<br />
qualifications<br />
Describe your<br />
commitment to the<br />
philosophy, intent<br />
and implementation<br />
of the New Model<br />
including those<br />
aspects of the New<br />
Model you think are<br />
significantly different<br />
from current<br />
disability supports<br />
List any particular<br />
areas of interest or<br />
expertise in relation<br />
to specific parts of<br />
the New Model<br />
Networks you can<br />
commit to report to<br />
National Reference <strong>Group</strong> <strong>Nomination</strong> <strong>Form</strong> 2
New Model for Supporting Disabled People<br />
National Reference <strong>Group</strong><br />
Referees or<br />
endorsements from<br />
disability<br />
organisations or<br />
people in the<br />
disability sector<br />
Please note contact details for at least two referees the selection panel<br />
can contact..<br />
If you have any<br />
conflicts of interest<br />
please note them<br />
Tick box:<br />
I am available for both of the currently planned meetings:<br />
<br />
<br />
Friday 29 April<br />
Thursday 26 and Friday 27 May<br />
Signature<br />
Email or post<br />
completed forms to<br />
Lawrence Chok<br />
email inclusionaotearoa@gmail.com<br />
4 Fernwood Place, Fitzherbert, Palmerston North 4410<br />
National Reference <strong>Group</strong> <strong>Nomination</strong> <strong>Form</strong> 3
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