Executive Advisory Board Member Nomination Form

Executive Advisors are responsible for advising on clinical policies and procedures, crisis response, policies related to research conducted by outside organizations, and other issues as they arise. The committee will be composed of a mixture of professionals who work with AS populations, parents of AS individuals, and adults with AS, all with an expertise or interest in clinical issues. Clinical Advisors are appointed by the Executive Director for a one year term and may be re-appointed annually at the discretion of the Executive Director.

If you are interested in being on this committee, you can call Dania at (866) 597-AANE x303, have someone nominate you using the form below, or use it to nominate yourself.

 

Nominee's Information:

Name
Address
Home Phone
Work Phone
Cell Phone
E-mail Address
Nominee is a(n):
(Disclosure is Voluntary)		 Adult with AS
Parent of an individual with AS
Relative of a person with AS
Professional who works with someone with AS
Teen with AS
No connection to AS
Other

 

Occupational Experience/Information:

Current Occupation
Title
Company/Organization
Company Address
Phone
Professional or Other Experience (if relevant to board membership)

 

Volunteer Experience:

Prior or Current AANE Volunteer, or Other Service Provided to AANE? Yes   No
Describe:
Membership on Executive Advisory Board of other organizations? Yes   No
Name and Address, and Type of Organization(s)
Other Relevant Volunteer Experience
Professional or Other Experience (if relevant to board membership)

 

Why is this nomination being made? What are this nominees strengths and/or skills, and what can he or she add to AANE as a member of the Executive Advisory Board?:

 

Is there anyone else the nominating committee can talk to about this person?

Name
E-mail Address

 

Individual submitting nomination (if other than self-nomination):

Name
Address
Home Phone
Cell Phone
E-mail Address
Relationship to Nominee