• North Los Angeles County Regional Center

    North Los Angeles County Regional Center

  • North Los Angeles County Regional Center

    APPLICATION - BOARD OF TRUSTEES

  • Attention: Board Support

  • Mailing Address:

    North Los Angeles County Regional Center

    Attention: Board Support

    9200 Oakdale Avenue, Suite 100 Chatsworth, CA 91311 

    Email Address: Boardsupport@nlacrc.org

    Regional center boards are governed by extensive conflict of interest standards. To assure that you would not have any conflict of interest, it is necessary that you read, sign and return the enclosed Conflict of Interest Statement with your application.

    The Bylaws of NLACRC require that persons serving on the Board of Trustees reside or work in the area served by this regional center (San Fernando, Santa Clarita, and Antelope Valleys

    The board generally meets the second Wednesday of each month, at 6:00 p.m. The meetings are open to the public and we strongly recommend that you attend our meetings to better understand the trustee’s role. The board meeting schedule is included in your packet. Please note that all board meetings are currently being held via Zoom and may resume to in-person in the upcoming future, additional information will be provided.

    Should you have any questions, please send us an email to Boardsupport@nlacrc.org. Thank you again for your interest in serving on our Board. We look forward to receiving the information requested!

    Sincerely,

    NLACRC Board Support 

    Attachment(s): Board of Trustees Application and Conflict of Interest Form

     

    Instructions: 

    After you have completed this application and conflict of interest statement, please email your resume and a statement of interest to boardsupport@nlacrc.org.  

     

    Supporting people with developmental disabilities in the San Fernando, Santa Clarita, and Antelope Valleys since 1974.

  • North Los Angeles County Regional Center

    APPLICATION - BOARD OF TRUSTEES

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • I am a member of the following developmental disability, health, or other community organizations:

  • Do you have experience in any of the following areas?
  • Status
  • If you are a relative of a regional center consumer, please indicate if the consumer:
  • I represent the following developmental disabilities:

  • Ethnicity:

  • of Hispanic/Latino origin? Indicate: Hispanic /Latino (H) OR Not Hispanic/Latino (NH). Select one.

  • Race:

  • Indicate: American Indian/Alaskan Native (AN), Asian (A), Black/African American (B), Pacific Islander (PI), White (W), Some other race alone (O). Select all that apply. If more than one race is selected, it will fall under the category "Two or more races
  • Do you work for an agency vendored by the North Los Angeles County Regional Center?
  • Do you have a family member that works for an agency vendored with the North Los Angeles County Regional Center?
  • Date
     / /

  • CONFLICT OF INTEREST REPORTING STATEMENT

  • State of California–Health and Human Services Agency

    DS 6016 (Rev. 08/2013)

    CONFLICT OF INTEREST REPORTING STATEMENT

    The duties and responsibilities of your position with the regional center require you to file this Conflict of Interest Reporting Statement. The purpose of this statement is to assist you, the regional center and the Department of Developmental Services (DDS) to identify any relationships, positions or circumstances involving you which may create a conflict of interest between your regional center duties and obligations, and any other financial interests and/or relationships that you may have. In order to be comprehensive, this reporting statement requires you to provide information with respect to your financial interests.


    A “conflict of interest” generally exists if you have one or more personal, business, or financial interests, or relationships that would cause a reasonable person with knowledge of the relevant facts to question your impartiality with respect to your regional center duties. The specific circumstances and relationships which create a conflict of interest are set forth in the California Code of Regulations, title 17, sections 54500 through 54530. You should review these provisions to understand the specific financial interests and relationships that can create a conflict of interest.


    Please answer the following questions to the best of your knowledge. If you find a question requires further explanation and/or there is not enough space to thoroughly answer the question, please attach as many additional sheets as necessary, and refer to the question number next to your answer. If the regional center identifies a conflict involving you, it will be required to prepare a conflict resolution plan. Some relevant definitions have been provided in the footnotes to assist you in responding to this statement.


    You are required to file this Reporting Statement within 30 days of beginning your employment with the regional center or from the date that you are appointed to the regional center board or advisory committee board. You are then required to file an annual Reporting Statement by August 1st of every year while you remain employed with the regional center or while you are a member of the regional center board or advisory committee board. You must also file a Reporting Statement within 30 days of any change in your status that could result in a conflict of interest. Circumstances that can constitute a change in your status that can require you to file an updated Reporting Statement are described below in footnote one. 

  • A. INFORMATION OF REPORTING INDIVIDUAL

  • Regional Center Position/Title
  • Reporting Status:
  • New Appointment Date
     / /

  • *Change of status includes a previously unreported activity that should have been reported, change in the circumstance of a previously reported activity, change in financial interest, familial relationship, legal commitment, change in regional center position or duties, change in regional center, or change to outside position or duties. See California Code of Regulations, title 17, sections 54531(d) and 54532(d)

  • 2. Do you or a family member* work for any entity or organization that is a regional center provider or contractor?

  • *Family member includes your spouse, domestic partner, parents, stepparents, grandparents, siblings, stepsiblings, children, stepchildren, grandchildren, parent-in-laws, brother-in-laws, sister-in-laws, son-in-laws and daughter- in-laws. See California Code of Regulations, title 17, sections 54505(f).

  • 3. Do you or a family member own or hold a position* in an entity or organization that is a regional center provider or contractor?

  • *For purposes of this question, hold a position generally means that you or a family member is a director, officer, owner, partner, employee, or shareholder of an entity or organization that is a regional center provider or contractor. For a specific description of positions that create a conflict of interest in a regional center provider or contractor see the California Code of Regulations, title 17, sections 54520 and 54526.

  • 4. Are you a regional center advisory committee board member?
  • If yes, are you a member of the governing board or owner or employee of an entity or organization that provides services to the regional center or regional center consumers?
  • 5. If you are a regional center advisory committee board member and answered yes to all the questions in Question 4 above, do any of the following apply to you: (a) are you an officer of the regional center board; (b) do you vote on purchasing services from a regional center provider; or (c) do you vote on matters where you might have a financial interest?
  • 6. Do any of the decisions you make when performing your job duties with the regional center have the potential to financially benefit you or a family member* ? [Note: Governing board members do not have to answer “yes” to this question if the financial benefit would be available to regional center consumers or their families generally].

  • *Generally, a decision can financially benefit you or a family member if the decision can either directly or indirectly cause you or a family member to receive a financial gain or avoid a financial loss. For a specific description of the types of decisions that can result in a financial benefit to you or a family member see the California Code of Regulations, title 17, sections 54522 and 54527. 

  • 7. Are you responsible for negotiating, making*, executing or approving contracts on behalf of the regional center?

  • *California Code of Regulations, title 17, sections 54523(b)(2) and 54528(b)(2) describes the types of conduct which constitute involvement in the making of a contract.

  • 8. Do you have financial interest in any contract* with the regional center?
  • If yes, did you negotiate, make, execute or approve the contract on behalf of the regional center?

  • *For purposes of questions 8 and 9, a financial interest in a contract generally means any direct or indirect interest in a contract that can cause cause you or a family member to receive any sort of financial gain or avoid any sort of financial loss irrespective of the dollar amount. California Code of Regulations, title 17, sections 54523 and 54528 define when financial interests in a contract will occur. 

  • 9. Do any of your family members have a financial interest in any contract with the regional center?
  • If yes, did you negotiate, make, execute or approve the contract on behalf of the regional center?
  • 10. Do you evaluate employment applications or contract bids that are submitted by your family member(s)?
  • 11. Your job duties require you to act in the best interests of the regional center and regional center consumers. Do you have any circumstances or other financial interests not already discussed above that would prevent you from acting in the best interests of the regional center or its consumers?

  • B. ATTESTATION

  • I,* HEREBY CONFIRM that I have read and understand the regional center’s Conflict of Interest Policy and that my responses to the questions in this Conflict of Interest Reporting Statement are complete, true, and correct to the best of my information and belief. I agree that if I become aware of any information that might indicate that this statement is not accurate or that I have not complied with the regional center’s Conflict of Interest Policy or the applicable conflict of interest laws, I will notify the regional center’s designated individual immediately. I understand that knowingly providing false information on this Conflict of Interest Reporting Statement shall subject me to a civil penalty in an amount up to fifty thousand dollars ($50,000) pursuant to Welfare and Institutions Code section 4626. 

  • Date
     / /

  • Upload Additional Materials

    Please upload your resume and personal statement of interest here, or email both to boardsupport@nlacrc.org
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