FEDERALLY MANDATED DISTRICT OF COLUMBIA PROTECTIVE SERVICES
CITIZENS REVIEW PANEL
APPLICATION FOR VOLUNTEER SERVICES
NAME: ___________________________________________________________
ADDRESS:_________________________________________________________
_________________________________________________________
WARD: _______________
PHONE: ___________________________________________________________
(home)
(other phone)
(cell)
E-MAIL ADDRESS__________________________________________________
GENDER: __________________________________________________________
ARE YOU EMPLOYED?: ___________YES ____________NO
TYPE OF EMPLOYMENT: ____________________________________________
RACE/ETHNICITY:
_____BLACK
_____WHITE
_____HISPANIC
_____ASIAN
_____MULTI-RACIAL
_____OTHER, NOT LISTED:________________________
Please attach your resume and two letters of reference with
this application form.
FEDERALLY MANDATED DISTRICT OF COLUMBIA PROTECTIVE SERVICES
CITIZENS REVIEW PANEL
APPLICATION FOR VOLUNTEER SERVICES
Please list any civic activities, including board or volunteer experiences in which you are
currently involved:
1)______________________________________________________________________
_______________________________________________________________________
2)______________________________________________________________________
_______________________________________________________________________
3)______________________________________________________________________
_______________________________________________________________________
Please share any areas in which you have knowledge or experience, including, but not
limited to any personal, family, or professional experience with services to abused and
neglected children.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please share any potential conflicts of interest that you may have while serving on the
Citizens Review Panel, including, but not limited to personal or professional experience
with services provided by the Cabinet for Families and Children.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please share with us your reasons for wanting to serve on the DC Child Protective
Services Citizens Review Panel.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
FEDERALLY MANDATED DISTRICT OF COLUMBIA PROTECTIVE SERVICES
CITIZENS REVIEW PANEL
APPLICATION FOR VOLUNTEER SERVICES
So that the panel may have the broadest citizen representation possible, please check the
category (or categories) you believe apply to you:
__Business Community
___Housing
__Child & Family Advocate
__Human Services Professional
__Child Attorney
__Judiciary/Court
__Childcare Worker
__Law Enforcement
__Child Healthcare Services
__Legislative/Policy
Expert
__Communications/Media
__Mental Health
__Concerned Citizen
__Person with
Parenting Experience
__Family Support/Preservation
__Private Provider
__Foster Care/Adoptive Parent
__Self-Help Group
__Higher Education
__Substance Abuse Service Provider
I am submitting my name for consideration for a position with the Federally Mandated
DC Child Protective Services Citizens Review Panel.
___________________________________________________
Signature
_________________
Date
Please submit your application and other requested documents by mail or e-mail to:
Joyce N. Thomas
President and CEO
Center for Child Protection and Family Support
CRP Facilitator
714 G Street, SE
Washington, DC 20003
joyce@centerchildprotection.org
If you have questions, please call our office at 202-544-3144.