California Children’s Services Family Advisory Committee

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Family Advisory Committee Interest Form

Thank you for your interest in becoming a member of the Kaiser Permanente Whole Child Model Family Advisory Committee (FAC). The purpose of this committee is to discuss the needs and concerns of families of children who are eligible for California Children’s Services (CCS).

Fill out the interest form below to get started.

Please complete and submit the form below. A member of our team will reach out to you with more information.

ErrorPlease correct the error(s) below

First Name Error
Last NameError
Phone Number Error
Email Address (optional) Error
Will you require interpretation services?Error
Select your language preference Error
If selected for the committee, can you commit to attending a virtual FAC meeting once every three (3) months?Error

All fields required except marked as optional

First Name

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Middle Initial (optional)

Last Name

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Phone Number

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Email Address (optional)

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Select your language preference

Arabic
Chinese
Farsi
Hmong
Russian
Spanish
Tagalog
Vietnamese
Other

Select a language option from the list

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If selected for the committee, can you commit to attending a virtual FAC meeting once every three (3) months?

Yes

No

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