Application for membership on the Healthy Chula Vista Advisory Commission

1

Prefix

Prefix

Mr.

Mrs.

Ms.

Mx.

Dr.

Other: If other, type text here.

N/A

2

Preferred Pronoun 

Preferred Pronoun

He/Him/His

She/Her/Hers

They/Them/Theirs

Ze/Hir/Hirs

Ey/Em/Eirs

Other: If other, type text here.

3

First and Last Name

 *

First and Last Name

4

Email

 *

Email

5

Residence Address

 *

Residence Address

6

City

City

7

ZIP Code

 *

ZIP Code

8

Primary Phone

 *

Primary Phone ext.

9

Secondary Phone

Secondary Phone ext.

10

I certify that I am a resident of the City of Chula Vista and at least 18 years of age.

When applying for a Youth Advisory member: I am a resident of the City of Chula Vista and between 16 and 22 years of age.

 *

I certify that I am a resident of the City of Chula Vista and at least 18 years of age. When applying for a Youth Advisory member: I am a resident of the City of Chula Vista and between 16 and 22 years of age. (Select an Answer) Yes No

11

How long have you been a resident of the City?   

How long have you been a resident of the City?

12

Please click here to view the interactive map and verify your District of residency

I am a resident of the following City Council district.

 *

Please click here to view the interactive map and verify your District of residency I am a resident of the following City Council district. (Select an Answer) 1 2 3 4

13

Employer

 *

Employer

14

Occupation

 *

Occupation

15

Have you ever been employed by the City of Chula Vista?

 *

Have you ever been employed by the City of Chula Vista?

Yes

No

16

If you have worked for the City of Chula Vista please provide the department and dates of employment. 

If you have worked for the City of Chula Vista please provide the department and dates of employment.

17

Please select the seats for which you are interested and qualify: (select as many as applicable)

 *

Please select the seats for which you are interested and qualify: (select as many as applicable)

Expert Representative

Youth Advisory Member (non-voting) - 16 to 22 years of age.

District Representative

18

Please indicate area(s) in which you have expertise and experience, or select None: (select as many as applicable)

 *

Please indicate area(s) in which you have expertise and experience, or select None: (select as many as applicable)

Land Use

Transportation

Nutrition

Health Care

Physical Activity

Environment

None of the above (You may still be considered to represent the district in which you live.)

19

If you selected one or more of the areas of expertise and experience above, please describe your expertise and experience that you would bring to the selected area(s). (250 words or less)

 *

If you selected one or more of the areas of expertise and experience above, please describe your expertise and experience that you would bring to the selected area(s). (250 words or less)

20

 *

I understand if I am appointed to a seat that represents my district, I must maintain my residency and elector status throughout my terms to remain eligible.

21

Have you previously served, or do you currently serve, on a Chula Vista Board, Committee or Commission

 *

Have you previously served, or do you currently serve, on a Chula Vista Board, Committee or Commission

Yes

No

22

If yes, which one(s) and for what period of time?

If yes, which one(s) and for what period of time?

23

Per Chula Vista Municipal Code Section 2.25.030, I understand:

-If I am currently serving on a board or commission, I must resign from my current board or commission if I am appointed.

-I must have served at least 12 months on my current board or commission in order to be appointed to another board or commission.

 *

I have read and acknowledged the above statement.

24

Are you, or have you been, involved in any local, civic, service or community groups?

 *

Are you, or have you been, involved in any local, civic, service or community groups?

Yes

No

25

If yes, please list them

If yes, please list them

26

What do you hope to accomplish in the role of a Health Wellness and Aging Commissioner? (250 words or less)

 *

What do you hope to accomplish in the role of a Health Wellness and Aging Commissioner? (250 words or less)

27

You may upload a resume in addition to your application (optional).

You may upload a resume in addition to your application (optional). Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

28

The City understands meeting schedules and individual's availability may change. We ask that you consider the meeting schedule when submitting an application.

I have reviewed the Health Wellness and Aging Commission regular meeting date, time and frequency.

29

 *

I am familiar with the responsibilities of the Health Wellness and Aging Commission. I attest that the information I have provided is accurate and true.

30

 

 *

I understand that this application and any documents submitted in connection with the application process are public records and may be publicly disclosed.

31

Where did you hear about this vacancy?

Where did you hear about this vacancy?

City’s Social Media

Chula Vista Library

City’s Website

City Employee

City Board/Commission Member or Staff

Other (please enter text below) If other, type text here.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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