MFAC Application Member and Family Advisory Council Name(Required) First Last Email(Required) Phone(Required)Preferred contact method(Required) Email Phone Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you a LIFEPlan CCO:(Required) Member/Self-advocate Family Member of Caregiver Region(Required) Hudson Valley Southern Tier North Country Central New York Mohawk Valley Capital How long have to been involved with services for yourself or your loved one?(Required)Why do you want to join the Member and Family Advisory Council (MFAC)?(Required)What special interests, skills, or experience can you offer to the MFAC?(Required)Are you affiliated with any other groups or organizations that could be helpful to the council?(Required)What areas do you have the most experience with?(Required) Self-Direction Housing Benefits and Entitlements Complex Medical Needs Complex Behavioral Needs Other Explain other areas of experience: