West Virginia Traumatic Brain/Spinal Cord Injury Rehabilitation Fund Board

Nomination for Governing Board

The West Virginia Traumatic Brain / Spinal Cord Injury Rehabilitation Fund Board, Chapter 18, Article 10K of the West Virginia Code, was created to establish criteria for and oversee the administration of the disbursement of Funds for You moneys; and through its mission works with various agencies, organizations and groups to ensure the implementation of the State Plan for traumatic brain injury.

The law requires that the board be composed of:
•	The following West Virginia agency representatives or assigned designee: Department of Education and Arts secretary, Health and Human Resources secretary, State Superintendent of Schools, Department of Military Affairs and Public Safety secretary, Bureau of Behavioral Health director, Division of Rehabilitation Services director, Bureau of Medical Service director, Department of Veterans Assistance, Office of Emergency Services director, and Insurance Commission director.
•	Seven members to represent public and private health organizations or other disability coalitions or advisory groups.
•	Seven members who are either survivors of traumatic brain or spinal cord injury or family members of persons with traumatic brain or spinal cord injury.

No member of the board may receive personal assistance services through this program.			
NAME:		
ADDRESS:	
CITY:	COUNTY:	STATE:	ZIP:	
DAY PHONE:	EVENING PHONE:	FAX:	
E-MAIL:	*BIRTH DATE:	*SEX:	*RACE:	
* This information is voluntary and is requested only to assist the Board in ensuring diversity.	
MISSION:
The mission of the TB/SCI Rehabilitation Fund Board is to enhance the quality of life of West Virginians of all ages with traumatic brain and/or spinal cord injury and their loved ones through a consumer-driven continuum of supports.	
RESPONSIBILITIES OF THE BOARD:
•	Oversee the administration of Funds for You moneys.
•	Offer direction to agencies and legislators in the implementation of expanding traumatic brain injury and spinal cord injury services.
•	Address new and ongoing policy and legislation concerning traumatic brain injury and spinal cord injury
•	Provide broad public awareness and prevention activities.
	
RESPONSIBILITIES OF BOARD MEMBERS:
 Board members will be expected to:
•	Attend and participate in all board meetings.
•	Declare any conflict of interest on decisions to be made by the board.
•	Refrain from applying for services provided by the program while serving on the board.

PLEASE EXPLAIN YOUR INTEREST IN SERVING ON THE BOARD AND YOUR EXPERIENCE/QUALIFICATIONS.  ATTACH ADDITIONAL SHEETS IF NEEDED.

	
THREE PEOPLE WHO WOULD RECOMMEND ME FOR A POSITION ON THIS BOARD ARE:	
NAME:	ADDRESS/ORGANIZATION:	DAYTIME PHONE:	

			

			

			
Questions regarding the board or the application process may be directed to:	

Ginger Dearth, Chair
c/o Bonnie Hicks
TB/SCI Rehabilitation Fund Board
959 Hartman Run Road
Morgantown, WV 26505
	
Telephone: (877)724-8244
Fax: (877)530-7734	

I certify that the information I have given in this application is true and accurate to the best of my knowledge and that I understand and agree to meet my responsibilities as a board member should I be selected to serve.

________________________________________________	_		____________________
Signature of Nominee									Date