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Master Aging Plan (M.A.P.) Participant Application <br />Name <br />Place of Employment <br />Address <br />Daytime Phone <br />Email address <br />Evening Phone <br />Fax <br />To ensure diversity of committees, please provide us with the following. (check} <br />13 <br />Gender. Male _ Female _ Age: Under 30 _ 30 - 45 _ 46 - 60 _ 61- 75 _ 76 + _ ; Disabled: Yes_ No <br />Ethnic Background: African-American _ Caucasian _ Native American _ Hispanic _ Asian _ Other _ <br />Township Residence: Bingham _ Hillsborough _ Chapel Hill _ Cedar Grove _ Cheeks _ Eno _ Little River _ <br />The MA.P. Steering Committee will be formed as well as three functional workgroups. Please rank the <br />following groups in order of your preference of participation, with "1" indicating your most preferred <br />and "4" indicating your least preferred. <br />MAP Steering Committee -responsible for analying, clarifying and expanding on functiozul stags <br />subcommittee reports and preparing the strategic plan for submission to the County Commissioners, <br />United Way and other elected town officials. <br />The Wel~/Fit Older Adult Subcommittee -Focus will be on wellness and prevention for this older <br />segment which represents approx. T9% of 60+ population <br />The Disabled/Moderately Impaired Older Adult Subcommittee - Focus will be supportive home and <br />community based long term care for. this older segment which represent approx. l6% of 60 + population. <br />The Severely Impaire~/Institutionalized Older Adult Subcommittee -Focus will be continual and protective <br />care in the home or residential facility for this older segment representing approx. 5% of 60+ population. <br />Please list any education, work experience, board experience or personal experience relevant to helping <br />develop the M.A.P. (Use the back of application and attach resume if necessary) <br />If selected, I agree to attend an orientation session for an overview of the M.A.P. process prior to being <br />assigned to a particular committee. <br />Signature Date <br />Please return to the Dept. on Aging, PO Box 8181, Hillsborough, NC 27278 by Friday, September 3,1999 <br />Job Title (if employed) <br />If you have questions, please contact Jerry Passmore at %7-9251 ext. 2009. or Email: jpassmore®co.orange.nc.us <br />