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LGBTQ+ Advisory Panel - Member Application
First Name
Last Name
Chosen or Preferred Name (if applicable)
Organization, Company or Affiliation (current or most relevant in recent past)
Pronouns
She/Her
He/Him
They/Them
Ze/Zir
Self-Identify
Other
Email
Mobile Phone Number
Address
Gender Identity
Male
Female
Trans Male
Trans Female
Two-Spirit
Non-Binary, Gender Non-Conforming, or Gender Fluid
Decline to Answer
Other
Sexual Orientation
Straight
Gay
Lesbian
Bisexual
Pansexual
Queer
Questioning/Unsure
Decline to Answer
Other
Racial Identity
African American or Black
Asian or Pacific Islander
Latino/a
Native American or Indigenous
White/Caucasian
Decline to Answer
Multi-Racial or Other (Please use both below to specify)
Other
How did you hear about this opportunity to serve on the LGBTQ+ Advisory Panel?
Professional Fields of Experience or Types of Organizations/Institutions You’ve Served:
Government Agency (Public Health, Mental Health, or other)
Social Services
Academia or Educational Institution
Media (Journalism, Advertising, Marketing, Influencer)
Community-Based Organization or Non-Profit
LGBTQ+ Advocacy Organization
Other
Professional Areas of Expertise and Relevant Experience :
Research and Evaluation
Media Campaigns or Public Education Initiatives
Youth Services
Training or Technical Assistance
Social Justice Advocacy
Mental Health Programming
Other
What is your experience relevant for an LGBTQ+ initiative?
Professional experience working with or in LGBTQ+ communities
Professional experience developing content or programs tailored for LGBTQ+ audiences
Lived experience as a member of the LGBTQ+ community
Other
Please describe any professional, personal, or lived experience related to mental, emotional, and behavioral health (if relevant).
Please select your preferred types of engagement as a potential member of the panel (noting only the first item is required for participation on panel, the others are optional)
*Virtual Attendance at Quarterly Meetings (minimum level)
Virtual Attendance at Monthly Meetings
Ad Hoc Calls as Needed to Consult on Specific Questions or Review Documents
Email Responses as Needed to Consult on Specific Questions or Review Documents
Responding to Surveys or Polls
In-person Attendance at Meetings in Sacramento, California
Other
Please tell us your eligibility and preference for participation incentives or compensation?
I am an employee of the State of California, the United States Federal Government, or are otherwise ineligible for incentives for my participation.
I am eligible for incentive and would prefer to be compensated for my time and participation.
I am eligible for incentive, but would prefer to donate my time.
Anything else you'd like to share about yourself or your experience to help us determine the best fit for the panel
Submit
