APS School Health Advisory Board
2017-18 Membership Form

Please complete the following form to join the APS School Health Advisory Board for the 2017-18 school year, or to cancel an existing membership. Parents, students and community members are welcome to join. SHAB meets every other month (5 times per year) and members are expected to attend at least 2 in-person meetings. Past members must re-join or cancel using this form.

Member information will be used to create an email distribution list for meeting announcements and news, and a membership roster for the School Board. Members can opt-in to having their names also posted on the SHAB website. For more information about SHAB, please visit the website: www.apsshab.weebly.com or visit the Facebook page: www.facebook.com/apsshab.

Much of this school year will be devoted to assisting schools with the new Wellness Policy and Policy Implementation Procedures. They will require each school to form a Wellness Council, conduct a standardized self-assessment, and report annually on wellness activities and progress. Please review the PIP to familiarize yourself with these mandates:

https://www.apsva.us/wp-content/uploads/2015/02/25-3-support-for-students-wellness-PIP.pdf

About You

I hereby: *

Renew my existing membership in SHAB for the 2017-18 school year

Request new membership in SHAB for the 2017-18 school year

Cancel my previous membership in SHAB

Why are you cancelling your previous membership in SHAB? (select all that apply)

No longer have children in APS

No longer a student at APS

Meeting times not convenient

Meeting location not convenient

Loss of interest in SHAB activities or priorities

No time/too many other obligations

Other: Other:

I wish to have my membership information made available (select all that apply): *

To SHAB leadership (required)

To the School Board (required)

On the SHAB website (optional, name only)

First Name *

Last Name: *

Any relevant degrees or credentials to include after your name? (i.e. RN, MPH, MD, RD, MPP, etc.)

Email: *

Are you a: (select all that apply) *

Title or Occupation (optional)

Organization/Employer (optional)

Which APS schools do you or your children currently attend? *

Name the schools referenced above: (insert a comma between each school)

Do you want the specific school names listed on your online SHAB member listing?

Yes

No, this is for admin use only

SHAB Participation

Do you wish to serve on any SHAB Work Groups? (select up to 2)

Assessment and Best Practices

Nutrition and Physical Activity

Allergy and Anaphylaxis

Socio-Emotional Health

Environmental Health and Asthma

Are there specific topics you want SHAB to address this school year?

Are you interested in serving in any of the following leadership roles on SHAB? (select all that apply) *

SHAB Vice-Chair

Work Group Chair or Co-Chair

Secretary

No

Does the current SHAB meeting schedule work reasonably well for you? Meetings are held the third Wednesday of every other month from 4:00-5:30 p.m. *

Yes

Not ideal, but OK

No

If no, what meeting schedule options would you prefer? (select all that apply)

Where would you prefer SHAB meetings be held? *

The Education Center at 1426 N Quincy St. (at W-L High School)

The Sequoia/Syphax Building at 2110 Washington Blvd (near Rte 50)

No preference

How do you get information about SHAB? (select all that apply) *

Facebook page (facebook.com/apsshab)

SHAB Website (apsshab.weebly.com)

SHAB emails from Chair

Other: Other:

SHAB member since: (admin use only - not published) *

2008-09 and earlier
2009-10
2010-11
2011-12
2012-13
2013-14
2014-15
2015-16
2016-17
Don't remember
N/A - new member