Apply to be a Member

Planning Council Membership Application

Please note, this online application form will be transmitted by e-mail, which may not be secure. If you have concerns about answering any of the questions provided in an online form, please feel free to download a PDF version of the application, which can be submitted in person at NORAPC’s office. Additionally, you are also welcome to come to the office in person during business hours to submit an application for membership. Thanks!

Name

Date

Mailing Address

City/State/Zip Code

E-mail Address

Day Phone

Night Phone

DEMOGRAPHIC INFORMATION IS COLLECTED TO ENSURE DECISIONS MADE ARE REPRESENTATIVE OF THE COMMUNITY AFFECTED BY HIV. NORAPC IS REQUIRED TO REPORT DEMOGRAPHIC INFORMATION OF APPLICANTS TO HRSA (FUNDING AGENCY), AND PERSONAL CONTACT INFORMATION MAY BE RELEASED TO THE OFFICE OF HEALTH POLICY FOR OFFICIAL RECORDS SHOULD AN APPOINTMENT BE MADE TO THE COUNCIL.

Gender

Male
Female
Unwilling to Disclose
Transgender or Nonconforming

Employee of a Ryan White Part A Funded Agency

No
I do not know
Yes

Conflict of Interest: All members must abide by the Conflict of Interest Policy of the Planning Council. Conflict of interest is defined as: Within the last six months, having a financial interest in, serving as a board member, being employed by or having a contract or agreement with, a corporation, partnership, or any other entity, whether public or private, that receives Ryan White Part A funds:

If so, Please Name the Agency Here:

Are You a Board Member of a Ryan White Part A Funded Agency?

No
I do not know
Yes

If Yes, Please Name the Agency Here:

Do You Have a Contract/Agreement With a Ryan White Part A Funded Agency?

No
I do not know
Yes

If Yes, Please Name the Agency Here:

Affiliated With Any Ryan White Programs

No
I do not know
Yes

If Yes, Please Name the Agency Here:

Receive Services From a Ryan White Part A Funded Agency

No
I do not know
Yes

If so, Please Name the Agency Here:

HIV DISCLOSURE: Members who are living with HIV may be reimbursed for reasonable expenses (childcare, travel, and personal care attendant). All HIV information will be kept strictly confidential.

I am not living with HIV (go to the next question)
I am living with HIV and willing to publicly disclose my status
I am living with HIV and am willing to disclose my status to the Nominating/Bylaws Committee and the NORAPC staff only, for the purpose of statistical reporting to HRSA
I am living with HIV, and I am NOT willing to publicly disclose my status

HEPATITIS C Disclosure: Are you a person living with HIV and Hepatitis C

I am Hepatitis C and HIV co-infected
Unwilling to disclose

All HIV and Hepatitis C information will be kept strictly confidential

Describe Your Work With Under-Served Populations:

Are you currently employed?

If Yes, Please State the Organization, Your Job Title, and Responsibilities:

Have You Ever Been a Caregiver For a Person Living with HIV/AIDS?

If Yes, Please Explain:

Please describe any work (volunteer and/or paid) that you have done, other than HIV related. Please list organizations, dates of service, and responsibilities

Have You Ever Worked For an Organization that Serves People Living with HIV/AIDS?

If Yes, Please Explain:

Have You Ever Worked For a Healthcare or Social Service Organization

If Yes, Please Explain:

Please list any other skills you have that you feel would be an asset at the Planning Council

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Please write your name to verify all information given is complete and accurate *

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Last

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