North Carolina Statewide Independent Living Council
Membership Application

Date:

Name:

Street Address:

City:                            State:                          Zip:           County:

Phone Number:
Email:

Why are you interested in becoming a member of North Carolina 
Statewide Independent Living Council?




Which Centers for Independent Living have you visited or with which 
State Independent Living programs (VR, VRILP, DSB) are you familiar?




What are some disability related Community activities that you are or 
were involved?






By law the NCSILC has to have a majority of people with significant 
disabilities representative of these following categories.  If applicable, 
please check all the areas that apply to you.


Seeing Disability

Learning Disability

Parent of an adult child with a disability

Hearing Disability

Cognitive Disability

Physical Disability

Emotional or Mental Health Disability

Parent of a school age child with a Disability

Systemic Disability (Lupus, CFIDS, renal, chemical/electrical  
sensitivity)