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OCPG Advisory Board Application

Questions marked with a * are required

Applicant Contact Information

First Name

Last Name

Phone

Email Address

How are you connected to OCPG and/or the problem gambling community?

What skills/expertise do you hope to bring to OCPG's Advisory Board?

	Please check all that apply
Business/Finance	Please check all that apply

Media/Communications	Please check all that apply

Politics/Policy/Advocacy	Please check all that apply

Prevention	Please check all that apply

Treatment/Recovery	Please check all that apply

Safer Gambling (RG)	Please check all that apply

Research	Please check all that apply

Education/Cirriculum Development	Please check all that apply

Institutional Memory	Please check all that apply

Contract Review/Legal Support	Please check all that apply

	Please check all that apply
Other	Please check all that apply

Please elaborate on your experience in areas you noted above:

Why do you wish to join OCPG's Advisory Board?

OCPG recognizes the need to embrace diversity and equality within its Board membership and any individuals it may employ. We ask the following questions as part of our effort to include diverse populations in our staff and volunteer leadership positions. Selection will be based on aptitude and ability and all questions are optional.

What is your gender?

Male

Female

Non-binary

Prefer not to state

Other

Are you a member of the LGBTQIA2S+ Community?

Yes

Prefer not to share

What is your race / ethnicity? (Check all that apply.)

American Indian or Alaska Native

Asian

Black

Indigineous

Latinx / Hispanic

Native Hawaiian or Other Pacific Islander

White / Caucasian

Prefer not to state

Other

What is your age?

18 - 24 years

25 - 34 years

35 - 44 years

45 - 54 years

55 - 64 years

65 - 74 years

75 years or older

Prefer not to state

Do you have lived experience with problem gambling

Prefer not to state

Yes

Is there anything else you wish to share?