SILC Membership Interest FormFirst Name(Required)Last Name(Required)Date of Birth(Required) Month Day YearPlease enter your date of birth in MM/DD/YYYY format.Gender(Required) Male Female non-binaryHome Address(Required)City(Required)County(Required)Select oneAlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrusCaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnettHaywoodHendersonHertfordHokeHydeIredellJacksonJohnstonJonesLeeLenoirLincolnMcDowellMaconMadisonMartinMecklenburgMitchellMontgomeryMooreNashNew HanoverNorthamptonOnslowOrangePamlicoPasquotankPenderPerquimansPersonPittPolkRandolphRichmondRobesonRockinghamRowanRutherfordSampsonScotlandStanlyStokesSurrySwainTransylvaniaTyrrellUnionVanceWakeWarrenWashingtonWataugaWayneWilkesWilsonYadkinYanceyPhone(Required)Email(Required) The Council is required by Federal law to have at least 51% of its members to be a person with a disability. Do you self -identify as a person with a disability?(Required) Yes NoIf yes, which category best describes your primary disability:(Required) Physical Cognitive Emotional/mental Hard of hearing or Deaf Low vision or blindThe Council strives for its membership to represent diverse cultural groups. Please check all that apply to you:(Required) LGBTQIA Caucasian Black/African American Native American Immigrant Asian Hispanic Prefer not to answerAre you a state employee?(Required) Yes NoAre you an employee, board member, or volunteer of a Center for Independent Living?(Required) Yes NoPlease list your affiliations with other boards, councils, commissions, or disability organizations:(Required)Please tell us why you would like to be a SILC Member:(Required)If you are not appointed right away by the Governor’s Office, would you be willing to volunteer with the SILC in one of the areas listed below?(Required) Yes NoPlease check which of the following areas you are most interested in:(Required) Communication and Media –Assist with various forms of communication which could include but are not limited to social media, flyers, announcements, newsletters, meeting minutes, templates, surveys, and data collection. Public Policy - Works on advocacy issues; researches and presents information and position statements for SILC approval before disseminating to the disability community, policy makers, the press and general public; and drafts educational advocacy letters to state and federal policy makers for SILC approval. State Plan of Independent Living (SPIL) - Gathers information to create a new three-year State Plan for Independent Living (SPIL); and monitors the progress of the current SPIL.Please attach a resume’ and any other relevant documents.Max. file size: 34 MB.If you do not fit the SILC’s current composition needs, we will hold your application for reconsideration for no less than six months. NameThis field is for validation purposes and should be left unchanged.