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CONSUMER ADVISORY COMMITTEE MEMBERSHIP APPLICATION
DS 254 (1/2022) (Electronic Version)

 
NOTE: The use of this form does not constitute consent to release confidential information that might be protected from disclosure pursuant to Welfare and Institutions Code sections 4514 and 5328, or other applicable state or federal law.
 
INSTRUCTIONS ON HOW TO FILL OUT DDS CAC APPLICATION
 
If you want help filling out this application, ask your friends, family, care provider, day program staff, regional center service coordinator, state developmental center staff, advocate, or anyone else you think will help   you.

1. Put your name under Name.
*Put the address of where you live under Address.
*Put your cellphone number (with area code) under Cellphone.
*Put your alternate phone number (with area code) under Alternate Phone Number.
*Put your email address under Email Address.
*Put the name of your regional center under Name of Your Regional Center.
*If you are a member of a local People First, or other self-advocacy
organization, put in the name of the group under Your Local Self-Advocacy Group.
2. Check whether you identify as a man, woman, or other.
3. Check the age group that you belong to.
4. Put in the names of any other boards, committees, and organizations
that you belong to such as regional center board, Regional Advisory Committees, etc.
5. Before you send in your application, DDS would like you to get a letter
of recommendation from an individual, or group that you are part of in your community, telling us why you would be great for this committee.
6. We want to know why you want to be a member of the Department of
Developmental Services Consumer Advisory Committee. Please use this space to tell us. You may add more pieces of paper if you need to. If you use more paper, be sure to include it when you send your application to DDS.
7. If you know who will be supporting you at CAC meetings, put in their
name and phone number.
8. Upload your letter of recommendation.
Contact Information:
Mail: Office of Legislation, Regulations and Public Affairs
          Department of Developmental Services
          1215 O Street, MS 9-10 
          Sacramento, CA 95814
          (916) 654-1494
Email: CAC@dds.ca.gov
                                   
 

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* 1. Your Personal Information:

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* 2. Are you a:

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* 3. Your age group:

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* 4. Do you serve on or belong to other boards, committees, and/or organizations?  If so, please tell us what they are?

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* 5. Please get a letter of recommendation from someone that can tell us why DDS should select you to be a member.

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* 6. Why do you want to be a member of the DDS Consumer Advisory Committee?

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* 7. If you want or need someone to support you at the CAC meetings, do you have someone in mind?

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* 8. Attach any supporting documentation/letter of recommendation

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