VCUSD COMMUNITY ADVISORY COMMITTEE FOR SPECIAL EDUCATION

APPLICATION FOR MEMBERSHIP

Name:

Address:

City/zip Code

Home Phone:

Work Phone:

Cell Phone:

Occupation:

Please Student Parent Staff / Professional

check one

Please General Special Other

check one Education Education

Area(s) of ADD / Emotional Health Impairment /Medi

interest ADHD Disabilities

Hearing Intellectual Learning Disabilities

Impairme Disabilities
nt/
Deafness

Multiple Neurological Orthopedic Disabilities

Disabilitie Disabilities
s
 VCUSD COMMUNITY ADVISORY COMMITTEE FOR SPECIAL EDUCATION
APPLICATION FOR MEMBERSHIP

Area(s) of Speech / Traumatic Transition

Interest Language Brain injury
Impairme
nt

Visual Undiagnosed Other

Impairme Disability
nt/
Blindness

Autism Fetal Alcohol

Spectrum Syndrome /
Disorders Disorder

Do you have Yes NO

a disability?

(We actively
seek CAC
members who
have
disabilities in
order to
ensure
representation
)

School
District:

Civic
activities or
organizatio
ns you
belong to, if
any:
 VCUSD COMMUNITY ADVISORY COMMITTEE FOR SPECIAL EDUCATION
APPLICATION FOR MEMBERSHIP

What do
you feel you
can
contribute
to the CAC?

How did you

hear about
the CAC?

Have you Yes No When?

attended
any CAC
meetings?

Signature: Date:

For CAC Use

Sent to Director:

Name Date

Number of CAC members from your district to

date:___________________________________________

Current membership comprised of:

Parents
Special Education teachers
Regular education teachers

Additional applications received from:

Parents
 VCUSD COMMUNITY ADVISORY COMMITTEE FOR SPECIAL EDUCATION
APPLICATION FOR MEMBERSHIP

Special Education teachers

Regular education teachers