Skip survey header

Palm Beach County HIV Care Council

Membership Application

1. APPLICANT INFORMATION
2. PROFESSIONAL INFORMATION
3. AFFILIATIONS
Are you a member of any advisory board or board of directors?
Are you a member of any county advisory boards?
Do you perform any consulting work related to health care, human services, or HIV/AIDS services?
Do you receive services from a Ryan White provider?
4. DEMOGRAPHIC INFORMATION - Please check all appropriate boxes.
Gender Identity:
Are you a male that identifies as gay, bisexual or a man who has sex with men? (MSM) (OPTIONAL)
Age:
Are you infected with Hepatitis C?
Are you infected with Hepatitis B?
Ethnic or Racial Origin:
Which membership categories pertain to you?
What are your areas of interest?
What committees are you interested in joining?
5. OTHER INFORMATION
Do you work for an agency that receives Ryan White or HOPWA funding?
Do you work for an agency intending to apply for Ryan White or HOPWA funds?
Are you representing the affected community?
Are you able to attend a minimum of two (2) committee meetings per month?
NOTICE TO APPLICANTS

As a member of the Palm Beach County HIV CARE Council, you are subject to Florida’s Government-In-The-Sunshine requirements. Certain personal requirements are placed upon you and your conduct with other members, the public at large and the Department of Community Services. Upon notification of appointment, all new members will undergo a new member orientation which will include complete discussion of Government-In-The- Sunshine.

Certain assurances pertaining to potential conflicts-of-interest must be executed by all members of the Palm Beach County HIV CARE Council. Disclosure of business and personal relationships with agencies or individuals benefitting from award of Ryan White Funding must be given each time an issue is raised which could present a conflict of interest. Council members must indicate prior to discussion any potential conflicts, and must abstain from voting on issues presenting a potential conflict.