Behavioral Institute for
Children and Adolescents
BICA Advisory Committee Application Completion of this form acknowledges that you have read the description of the BICA Advisory Committee and that you desire to serve on the Committee. Please provide the following contact information: First Name Last Name Middle Initial Organization (if applicable) Address Type Home Work Street Address Address (cont.) City State/Province Zip/Postal Code Country Work Phone (format xxx-xxx-xxxx) Home Phone (format xxx-xxx-xxxx) FAX(format xxx-xxx-xxxx) E-mail STATEMENT OF INTEREST: Please provide a brief statement describing your interest in participating on the BICA Advisory Committee: REFERRAL: Were you referred to submit an application by someone from the BICA staff, Board, faculty, or partnering organization? No Yes If yes, who? OPTIONAL OPPORTUNITIES FOR PARTICIPATION WITH BICA PROGRAMS: Please indicate which committees/programs interest you (select as many as apply) Publications Committee please click to select area of interest (hold down the shift key to make multiple selections) Author of books Editor/reviewer Newsletter contributor Scholarship Committee please click to select area of interest (hold down the shift key to make multiple selections) Publicity/application solicitation Fundraising Application reviewer International Conference Committee please click to select area of interest (hold down the shift key to make multiple selections) Presenter Strand Leader Promotions/public relations Other State Conferences Committee please click to select area of interest (hold down the shift key to make multiple selections) Presenter Local arrangements Promotions/public relations Other Topical Training Institutes & Contracted Services Committee please click to select area of interest (hold down the shift key to make multiple selections) Faculty Planning/local arrangements Other Grants & Research Committee please click to select area of interest (hold down the shift key to make multiple selections) Applications Collaboration Other Partnerships Program/Event Promotions Please use this space to make any notes regarding your application: Thank you for your application. You will be notified within one month. If you have any questions in the meantime, please contact us. M. KnollCopyright © 2007 [Behavioral Institute for Children and Adolescents]. All rights reserved. Revised: 01/24/08
Completion of this form acknowledges that you have read the description of the BICA Advisory Committee and that you desire to serve on the Committee.
Please provide the following contact information:
Organization
(if applicable)
Work Phone
(format xxx-xxx-xxxx)
Home Phone
STATEMENT OF INTEREST:
Please provide a brief statement describing your interest in participating on the BICA Advisory Committee:
REFERRAL:
Were you referred to submit an application by someone from the BICA staff, Board, faculty, or partnering organization?
No
Yes If yes, who?
OPTIONAL OPPORTUNITIES FOR PARTICIPATION WITH BICA PROGRAMS:
Please indicate which committees/programs interest you (select as many as apply)
Publications Committee
please click to select area of interest (hold down the shift key to make multiple selections)
Author of books Editor/reviewer Newsletter contributor
Scholarship Committee
Publicity/application solicitation Fundraising Application reviewer
International Conference Committee
Presenter Strand Leader Promotions/public relations Other
State Conferences Committee
Presenter Local arrangements Promotions/public relations Other
Topical Training Institutes & Contracted Services Committee
Faculty Planning/local arrangements Other
Grants & Research Committee
Applications Collaboration Other
Partnerships
Program/Event Promotions
Please use this space to make any notes regarding your application:
Thank you for your application. You will be notified within one month. If you have any questions in the meantime, please contact us.
Behavioral
Institute for